diff --git "a/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_2000_2500.json" "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_2000_2500.json" new file mode 100644--- /dev/null +++ "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_2000_2500.json" @@ -0,0 +1,33021 @@ +[ + { + "id": "multiclinsum_test_1835_en.txt", + "fulltext": "On 3rd November 2009, the first MCGR was implanted in a 5-year-old girl with Ehlers-Danlos Syndrome (type VI). This patient was born with generalized hypotonia and a flail right upper limb. She had a curve of 58.5 degrees at T1–9 and 72.8 degrees at T9-L4 with a single MCGR anchored at T3–4 and L3–4 . An extra short rod was placed on the other side to facilitate any additional MCGR without changing the foundation. At postoperative 13 months, the MCGR failed to distract between lengthening episodes due to unrestricted turning of the internal magnet. The rod returned to the pre-distraction state at follow-up indicating a loss of distraction. The unrestricted turning was observed through internal testing by the developer. There was increasing truncal shift and shoulder elevation. An external magnet was placed outside the skin to prevent the magnet from turning back . The rod was redesigned with an internal keeper plate added to prevent further loss of distraction . The overall balance was suboptimal and after the rod was used up, she developed proximal junctional kyphosis (PJK) as well as a “crooked rod sign” .\nAt 9-years-old, a set of dual MCGRs with the new design were inserted with extension proximally to C7-T1. Her spinal balance improved and distractions continued. She subsequently developed adding-on below . At 15-years-old, the rods failed to distract with frequent rotor stalling. A “crooked rod sign” was again observed on radiographs . No further distractions were possible. Autofusion was also observed in the lumbar spine. Final fusion surgery was performed from C7-L4 leaving a residual tilt below to avoid fusion to the pelvis as she was a candidate for the para-Olympics table tennis team and we wanted to maintain mobility. Gross metallosis observed around the actuator and extendable portion of the rod was debrided .\nThe rods were extracted for visual inspection, X-ray examination and dissection . On the external appearance, from the anteroposterior (AP) view, the two MCGRs were aligned. However, from the lateral view, the piston rod in the left MCGR showed a “crooked rod sign” close to the barrel opening. Dissection of the left rod revealed that the “crooked rod” radiographic sign was caused by fracture of the stud close to the barrel opening . The rotor and stud could not drive the piston rod to extend due to this complete material failure. Part of the stud remained inside of the piston rod and the fracture site could have repetitive frictions caused by rod stalling during distraction sessions with magnet rotation. Corrosion could be seen at the stud fracture site and the barrel opening of the sleeve portion .\nAdditionally, the debris from inside of the sleeve was collected on petri dishes and observed under light microscopy . Morphologically, wear particles were seen for the left rod with fracture , whereas for the right rod, the debris was larger and had the appearance of screw thread tracks . The concentrations of elements (mg/kg) in the sample were measured by inductively coupled plasma optical emission spectrometers (ICP-OES; Agilent 700 Series; Agilent Technologies, Inc.; US). The testing process followed the instructions from the manufacturer . The ICP-OES revealed the elements from the debris contained both metal wear particles (Titanium, Aluminum, Vanadium, Neodymium) and human tissues (Calcium, Phosphate, Potassium, Sulfur, Sodium) . For the left rod there was predominantly metal particles, whereas for the right rod, elements from human tissues were increased.\nThe patient is now more than 2 years after the final fusion surgery with maintenance of the Cobb angle correction. The overall balance remains unchanged without any loosening of the implant.", + "fulltext_subclaims": [ + "On 3rd November 2009, the first MCGR was implanted in a 5-year-old girl with Ehlers-Danlos Syndrome (type VI).", + "This patient was born with generalized hypotonia and a flail right upper limb.", + "She had a curve of 58.5 degrees at T1–9 and 72.8 degrees at T9-L4 with a single MCGR anchored at T3–4 and L3–4.", + "An extra short rod was placed on the other side to facilitate any additional MCGR without changing the foundation.", + "At postoperative 13 months, the MCGR failed to distract between lengthening episodes due to unrestricted turning of the internal magnet.", + "The rod returned to the pre-distraction state at follow-up indicating a loss of distraction.", + "The unrestricted turning was observed through internal testing by the developer.", + "There was increasing truncal shift and shoulder elevation.", + "An external magnet was placed outside the skin to prevent the magnet from turning back.", + "The rod was redesigned with an internal keeper plate added to prevent further loss of distraction.", + "The overall balance was suboptimal and after the rod was used up, she developed proximal junctional kyphosis (PJK) as well as a “crooked rod sign”.", + "At 9-years-old, a set of dual MCGRs with the new design were inserted with extension proximally to C7-T1.", + "Her spinal balance improved and distractions continued.", + "She subsequently developed adding-on below.", + "At 15-years-old, the rods failed to distract with frequent rotor stalling.", + "A “crooked rod sign” was again observed on radiographs.", + "No further distractions were possible.", + "Autofusion was also observed in the lumbar spine.", + "Final fusion surgery was performed from C7-L4 leaving a residual tilt below to avoid fusion to the pelvis as she was a candidate for the para-Olympics table tennis team and we wanted to maintain mobility.", + "Gross metallosis observed around the actuator and extendable portion of the rod was debrided.", + "The rods were extracted for visual inspection, X-ray examination and dissection.", + "On the external appearance, from the anteroposterior (AP) view, the two MCGRs were aligned.", + "From the lateral view, the piston rod in the left MCGR showed a “crooked rod sign” close to the barrel opening.", + "Dissection of the left rod revealed that the “crooked rod” radiographic sign was caused by fracture of the stud close to the barrel opening.", + "The rotor and stud could not drive the piston rod to extend due to this complete material failure.", + "Part of the stud remained inside of the piston rod and the fracture site could have repetitive frictions caused by rod stalling during distraction sessions with magnet rotation.", + "Corrosion could be seen at the stud fracture site and the barrel opening of the sleeve portion.", + "Additionally, the debris from inside of the sleeve was collected on petri dishes and observed under light microscopy.", + "Morphologically, wear particles were seen for the left rod with fracture, whereas for the right rod, the debris was larger and had the appearance of screw thread tracks.", + "The concentrations of elements (mg/kg) in the sample were measured by inductively coupled plasma optical emission spectrometers (ICP-OES; Agilent 700 Series; Agilent Technologies, Inc.; US).", + "The testing process followed the instructions from the manufacturer.", + "The ICP-OES revealed the elements from the debris contained both metal wear particles (Titanium, Aluminum, Vanadium, Neodymium) and human tissues (Calcium, Phosphate, Potassium, Sulfur, Sodium).", + "For the left rod there was predominantly metal particles, whereas for the right rod, elements from human tissues were increased.", + "The patient is now more than 2 years after the final fusion surgery with maintenance of the Cobb angle correction.", + "The overall balance remains unchanged without any loosening of the implant." + ], + "summary": "A 5-year old girl with a scoliosis of 58.5 degrees at T1-9 and 72.8 degrees at T9-L4 had a single MCGR inserted and anchored at T3-4 and L3-4. At postoperative 13 months the MCGR was noted to have lost of distraction between lengthening episodes due to unrestricted turning of the internal magnet. To prevent further loss of distraction, an external magnet was placed outside the skin to prevent the magnet from turning back. The overall balance was suboptimal and after the rod was fully distracted, proximal junctional kyphosis occurred. Subsequently, the MCGR was modified with an internal keeper plate to prevent loss of distraction and a dual set of these rods were implanted when the patient was 9 years old. Extension proximally to C7-T1 was done to manage the proximal junctional kyphosis. Her spinal balance improved and distractions continued. She subsequently developed add-on below and the piston rod was not aligned with the actuator. The lumbar spine was also observed to have autofusion. She subsequently had final fusion surgery performed at the age of 15 from C7-L4 leaving a residual tilt below to avoid fusion to the pelvis. The final extracted rod on the left side indicated the \"crooked rod sign\" on X-ray and rod dissections revealed a new failure mechanism of stud fracture close to the barrel opening. Body fluids and tissue may infiltrate the rod despite no obvious deformation or fractures resulting in hastened wearing of the threads.", + "summary_subclaims": [ + "A 5-year old girl had a single MCGR inserted and anchored at T3-4 and L3-4.", + "At postoperative 13 months, the MCGR was noted to have lost distraction between lengthening episodes due to unrestricted turning of the internal magnet.", + "An external magnet was placed outside the skin to prevent the magnet from turning back.", + "The overall balance was suboptimal.", + "After the rod was fully distracted, proximal junctional kyphosis occurred.", + "The MCGR was modified with an internal keeper plate to prevent loss of distraction.", + "A dual set of these rods were implanted when the patient was 9 years old.", + "Extension proximally to C7-T1 was done to manage the proximal junctional kyphosis.", + "Her spinal balance improved and distractions continued.", + "She subsequently developed add-on below and the piston rod was not aligned with the actuator.", + "The lumbar spine was observed to have autofusion.", + "She had final fusion surgery performed at the age of 15 from C7-L4.", + "A residual tilt below was left to avoid fusion to the pelvis.", + "The final extracted rod on the left side indicated the 'crooked rod sign' on X-ray.", + "Rod dissections revealed a new failure mechanism of stud fracture close to the barrel opening.", + "Body fluids and tissue may infiltrate the rod despite no obvious deformation or fractures.", + "Hastened wearing of the threads may result from body fluids and tissue infiltrating the rod." + ] + }, + { + "id": "multiclinsum_test_1338_en.txt", + "fulltext": "We describe a 57-year-old right-handed female presenting to a neurology outpatient clinic with a chief complaint of weakness. She initially began to experience hypophonia, weakness and subsequent difficulty walking approximately one year prior, with hoarseness of speech starting even earlier. Initial onset of symptoms also involved bradykinesia, including speech and ambulation. She noted that her left upper and lower extremities were predominantly affected at onset, with subsequent spread to the right upper and lower extremities. In particular, she had difficulty typing, especially with her left hand, and over time developed micrographia with somewhat illegible handwriting. She experienced impaired gait and balance with a tendency to fall backwards and reported difficulty lifting her legs getting in and out of vehicles. She also endorsed stiffness and cramping in her legs.\nReview of systems was notable for vague lightheadedness, which she described as a \"fuzzy feeling\" or slowed mental processing. She had a history of constipation with infrequent bowel movements for several years and exhibited frequent episodes of yelling out at night for which the patient was amnestic. Remarkably, within about six months of disease onset she developed laughing involuntarily out of context. Throughout her symptomatic progression, she did not experienced fevers, chills, or other constitutional symptoms. Past medical history was limited to a diagnosis of shingles several years earlier without residual symptoms, and family history was negative for neurologic disorders including motor neuron disease and movement disorders.\nPhysical exam included normal orthostatics. Hypomimia was observed with no abnormalities of eye movements. Cognition was normal by Montreal Cognitive Assessment, but speech was hypophonic, slow and mildly dysarthric with hoarse monotone quality. Jaw jerk was absent, and there was no evidence for tongue atrophy or fasciculations. Power was normal without muscle atrophy or fasciculations. Hyperreflexia with Hoffmann's and suprapatellar reflexes were noted bilaterally. Mild bilateral lower extremity spasticity was slightly greater on the left with bilateral extensor plantar responses present. Gait was slow en bloc with bilaterally decreased arm swing. Mild bradykinesia was seen in the upper extremities but without cogwheeling or resting tremor appreciated. Subsequent further evaluation showed severely impaired finger tapping bilaterally and moderate postural instability.\nLaboratory studies including routine blood work and other testing were negative for autoimmune and paraneoplastic processes, vitamin deficiency, and metabolic disorders . Genetic analysis revealed a variant of uncertain significance in the PSEN2 gene . Electromyography was completely negative for lower motor neuron findings. Magnetic resonance imaging (MRI) of the brain both at nine months and two years from disease onset revealed atrophy mildly greater than expected for the patient’s age, particularly in the frontal and parietal cortices bilaterally symmetrical with a normal-appearing brainstem, including pons. Neither a hot cross bun nor putaminal rim sign was visualized . MRI of the cervical spine was essentially normal with minimal disc bulging and no intrinsic cord findings. A DaTscan roughly one year from symptom onset was markedly abnormal with no activity in the putamen bilaterally and diminished uptake in the caudate bilaterally, moderate on the right and mild on the left, confirming nigrostriatal dysfunction .\nFollow-up 2.5 years after initial symptom onset, the patient’s clinical course has been a very slow progression. She continues to have pathologically brisk reflexes with spasticity limiting functionality and increased tone impacting her dexterity and gait. Neuropsychological testing reveals normal cognition with exception of mild slowing in verbal construction and cognitive processing. Ocular motor function remains normal. She continues to exhibit mild asymmetry with both spasticity and bradykinesia slightly worse on the left, still without tremor. She ambulates independently and functions well in her job though challenged by hypophonia and difficulty typing. She has not developed orthostatic hypotension or other signs of autonomic failure. Treatment with tizanidine has helped symptoms of stiffness and cramping, and her bradykinesia has subjectively responded to levodopa titrated up to tolerance.", + "fulltext_subclaims": [ + "The patient is a 57-year-old right-handed female.", + "She presented with weakness.", + "She initially began to experience hypophonia, weakness, and difficulty walking approximately one year prior.", + "Hoarseness of speech started even earlier than the other symptoms.", + "Initial onset of symptoms also involved bradykinesia, including speech and ambulation.", + "She noted that her left upper and lower extremities were predominantly affected at onset.", + "Subsequent spread occurred to the right upper and lower extremities.", + "She had difficulty typing, especially with her left hand.", + "She developed micrographia with somewhat illegible handwriting.", + "She experienced impaired gait and balance with a tendency to fall backwards.", + "She reported difficulty lifting her legs getting in and out of vehicles.", + "She endorsed stiffness and cramping in her legs.", + "Review of systems was notable for vague lightheadedness described as a 'fuzzy feeling' or slowed mental processing.", + "She had a history of constipation with infrequent bowel movements for several years.", + "She exhibited frequent episodes of yelling out at night for which the patient was amnestic.", + "Within about six months of disease onset, she developed laughing involuntarily out of context.", + "She did not experience fevers, chills, or other constitutional symptoms.", + "Past medical history was limited to a diagnosis of shingles several years earlier without residual symptoms.", + "Family history was negative for neurologic disorders including motor neuron disease and movement disorders.", + "Physical exam included normal orthostatics.", + "Hypomimia was observed with no abnormalities of eye movements.", + "Cognition was normal by Montreal Cognitive Assessment.", + "Speech was hypophonic, slow, and mildly dysarthric with a hoarse monotone quality.", + "Jaw jerk was absent.", + "There was no evidence for tongue atrophy or fasciculations.", + "Power was normal without muscle atrophy or fasciculations.", + "Hyperreflexia with Hoffmann's and suprapatellar reflexes were noted bilaterally.", + "Mild bilateral lower extremity spasticity was slightly greater on the left.", + "Bilateral extensor plantar responses were present.", + "Gait was slow en bloc with bilaterally decreased arm swing.", + "Mild bradykinesia was seen in the upper extremities but without cogwheeling or resting tremor.", + "Subsequent further evaluation showed severely impaired finger tapping bilaterally.", + "Moderate postural instability was noted.", + "Laboratory studies were negative for autoimmune and paraneoplastic processes.", + "Laboratory studies were negative for vitamin deficiency and metabolic disorders.", + "Genetic analysis revealed a variant of uncertain significance in the PSEN2 gene.", + "Electromyography was completely negative for lower motor neuron findings.", + "MRI of the brain at nine months and two years from disease onset revealed atrophy mildly greater than expected for the patient’s age.", + "The atrophy was particularly in the frontal and parietal cortices bilaterally symmetrical.", + "The brainstem, including pons, appeared normal on MRI.", + "Neither a hot cross bun nor putaminal rim sign was visualized.", + "MRI of the cervical spine was essentially normal with minimal disc bulging.", + "There were no intrinsic cord findings on cervical spine MRI.", + "A DaTscan roughly one year from symptom onset was markedly abnormal.", + "The DaTscan showed no activity in the putamen bilaterally.", + "The DaTscan showed diminished uptake in the caudate bilaterally, moderate on the right and mild on the left.", + "The DaTscan confirmed nigrostriatal dysfunction.", + "Follow-up 2.5 years after initial symptom onset showed a very slow progression.", + "She continues to have pathologically brisk reflexes with spasticity limiting functionality.", + "Increased tone impacts her dexterity and gait.", + "Neuropsychological testing reveals normal cognition with exception of mild slowing in verbal construction and cognitive processing.", + "Ocular motor function remains normal.", + "She continues to exhibit mild asymmetry with both spasticity and bradykinesia slightly worse on the left.", + "She still does not have tremor.", + "She ambulates independently and functions well in her job.", + "She has not developed orthostatic hypotension or other signs of autonomic failure.", + "Treatment with tizanidine has helped symptoms of stiffness and cramping.", + "Her bradykinesia has subjectively responded to levodopa titrated up to tolerance." + ], + "summary": "This case report will review a 57-year-old Caucasian female who presented with pyramidal and extrapyramidal features suggestive of the exceedingly rare disease primary lateral sclerosis plus parkinsonism. We will describe the mixture of upper motor neuron signs and striking parkinsonian symptoms experienced by the patient, as well as the full diagnostic workup leading to her preliminary diagnosis. The details of this case will then be utilized to explore the diagnostic criteria of primary lateral sclerosis, as well as to work through the differential of conditions resembling Parkinson's disease.", + "summary_subclaims": [ + "The patient is a 57-year-old Caucasian female.", + "The patient presented with pyramidal and extrapyramidal features.", + "The features were suggestive of primary lateral sclerosis plus parkinsonism.", + "Primary lateral sclerosis plus parkinsonism is an exceedingly rare disease.", + "The patient experienced upper motor neuron signs.", + "The patient had striking parkinsonian symptoms.", + "A full diagnostic workup was performed.", + "The case will be used to explore the diagnostic criteria of primary lateral sclerosis.", + "The case will be used to work through the differential of conditions resembling Parkinson's disease." + ] + }, + { + "id": "multiclinsum_test_3214_en.txt", + "fulltext": "A 6-year-old right hand dominant female child was brought by her father to the emergency department with the history of a fall 2 h back, with the point of the extended and pronated left elbow making forceful contact with the edge of the step. She presented with a painful and deformed left elbow, and with inability to move her left forearm. It was tender, swollen, deformed and held in 40 degrees of flexion, with the support of the contralateral limb. The forearm seemed to be in a fixed and pronated state. Active range of movements were not possible, and trivial passive movements elicited pain. Radial artery pulsations were palpable. The hand was pink, warm and the fingers showed a capillary refill time of less than 2 s. On careful neurological examination, light touch sensation in the ulnar nerve territory of the left hand was decreased as compared to the other hand, with marked sensory diminution over the little finger. The pain, temperature, deep touch sensations and the motor examination of the left upper limb were unremarkable. Close examination of the radiographs revealed the presence of a posterior dislocation and convergent translocation of the left elbow, without any fracture.\n\nAn urgent MRI scan of the left elbow was performed to rule out cartilaginous and ligamentous injuries. MRI of the left elbow revealed dislocation of the ulno-trochlear and radio-capitellar joint, with the presence of hemarthrosis. It also showed articulation of the radial head with the humeral trochlea and of the ulnar olecranon with the humeral capitellum. The lateral collateral ligament and the lateral ulnar collateral ligament revealed full thickness tears at the proximal attachments, while the medial collateral ligament showed the same at the distal attachment. Bulkiness of the ulnar nerve was noticeable at the level of the distal end of the humerus along with an annular ligament tear.\n\nUnder short general anaesthesia and image intensifier control, the haematoma was aspirated percutaneously from the elbow joint, via a posterior portal. A closed reduction with a hyper-supination manoeuvre was then performed. Closed, stable reduction was achieved and a bivalved cast in 100 degrees of flexion and full supination was applied to hold the reduction and to immobilize the left elbow.\n\nThe patient was reviewed after 1 week, at which the radiographs showed a congruent left elbow joint with maintained reduction. Sensations of the left hand in the ulnar nerve territory, which were diminished at the initial presentation, were now restored and equal in both limbs. The bivalved cast was replaced by an above elbow full cast in full supination. The cast was removed at 4 weeks and a check radiograph showed the presence of a congruent elbow joint. Gradual rehabilitation including flexion-extension and pronation-supination were initiated. By the end of 2 months, the child had regained complete arc of range of motion. At the 6-month followup, there was no varus-valgus laxity which was confirmed clinically as well as with stress radiographs. Additionally, the QuickDASH score was found to be 2.3, Mayo Elbow Performance Score (MEPS) was found to be 95, and the child was seen to be carrying out all activities of daily life without any difficulties [8]. A similar radiological and functional outcome was found at the 1 year follow-up. We replicated the mechanism of this injury in the cadaveric lab on a preserved specimen of the elbow with intact osteoligamentous anatomy. This was done to depict the patho-mechanics of PRUT, on an illustrated cadaveric model to understand the cascade of events in this rare injury.", + "fulltext_subclaims": [ + "A 6-year-old right hand dominant female child was brought by her father to the emergency department.", + "The child had a fall 2 h back.", + "The point of the extended and pronated left elbow made forceful contact with the edge of the step.", + "She presented with a painful and deformed left elbow.", + "She had inability to move her left forearm.", + "The left elbow was tender, swollen, deformed, and held in 40 degrees of flexion.", + "The forearm was in a fixed and pronated state.", + "Active range of movements were not possible.", + "Trivial passive movements elicited pain.", + "Radial artery pulsations were palpable.", + "The hand was pink and warm.", + "The fingers showed a capillary refill time of less than 2 s.", + "Light touch sensation in the ulnar nerve territory of the left hand was decreased as compared to the other hand.", + "There was marked sensory diminution over the little finger.", + "The pain, temperature, deep touch sensations, and motor examination of the left upper limb were unremarkable.", + "Radiographs revealed the presence of a posterior dislocation and convergent translocation of the left elbow.", + "There was no fracture.", + "An urgent MRI scan of the left elbow was performed.", + "MRI revealed dislocation of the ulno-trochlear and radio-capitellar joint.", + "Hemarthrosis was present.", + "The radial head articulated with the humeral trochlea.", + "The ulnar olecranon articulated with the humeral capitellum.", + "The lateral collateral ligament and the lateral ulnar collateral ligament revealed full thickness tears at the proximal attachments.", + "The medial collateral ligament showed full thickness tears at the distal attachment.", + "Bulkiness of the ulnar nerve was noticeable at the level of the distal end of the humerus.", + "An annular ligament tear was present.", + "Under short general anaesthesia and image intensifier control, the haematoma was aspirated percutaneously from the elbow joint via a posterior portal.", + "A closed reduction with a hyper-supination manoeuvre was performed.", + "Closed, stable reduction was achieved.", + "A bivalved cast in 100 degrees of flexion and full supination was applied.", + "At 1 week, radiographs showed a congruent left elbow joint with maintained reduction.", + "Sensations of the left hand in the ulnar nerve territory were now restored and equal in both limbs.", + "The bivalved cast was replaced by an above elbow full cast in full supination.", + "The cast was removed at 4 weeks.", + "A check radiograph showed the presence of a congruent elbow joint.", + "Gradual rehabilitation including flexion-extension and pronation-supination were initiated.", + "By the end of 2 months, the child had regained complete arc of range of motion.", + "At the 6-month followup, there was no varus-valgus laxity.", + "This was confirmed clinically and with stress radiographs.", + "The QuickDASH score was 2.3.", + "The Mayo Elbow Performance Score (MEPS) was 95.", + "The child was seen to be carrying out all activities of daily life without any difficulties.", + "A similar radiological and functional outcome was found at the 1 year follow-up.", + "The mechanism of this injury was replicated in the cadaveric lab on a preserved specimen of the elbow with intact osteoligamentous anatomy.", + "This was done to depict the patho-mechanics of PRUT.", + "This was done on an illustrated cadaveric model to understand the cascade of events in this rare injury." + ], + "summary": "A 6-year-old female child presented to us with posterior elbow dislocation, PRUT and incomplete ulnar nerve palsy. A hematoma aspiration and reduction of the elbow joint were done with a hyper-supination manoeuvre to reverse the translocation. She was managed with an above-elbow cast for 4 weeks and showed good radiological and functional outcomes on subsequent follow-ups until 1 year.", + "summary_subclaims": [ + "The patient is a 6-year-old female child.", + "The patient presented with posterior elbow dislocation.", + "The patient had PRUT.", + "The patient had incomplete ulnar nerve palsy.", + "Hematoma aspiration was performed.", + "Reduction of the elbow joint was done.", + "A hyper-supination manoeuvre was used to reverse the translocation.", + "The patient was managed with an above-elbow cast for 4 weeks.", + "The patient showed good radiological outcomes on subsequent follow-ups.", + "The patient showed good functional outcomes on subsequent follow-ups.", + "Follow-ups continued until 1 year." + ] + }, + { + "id": "multiclinsum_test_2352_en.txt", + "fulltext": "A 70-year-old female came to the emergency department with the chief complaints of sore throat for 7 days. The pain was continuous and was radiating to the left ear and the left side of the neck. The pain was aggravated by swallowing both solid and liquid diet. The pain was also aggravated by neck movements. The patient complained of a severe headache and neck stiffness. The patient was also having fever for the same duration. There was no change in the patient voice. There was no breathing difficulty . The patient was on Amoxycillin-Clavulanic acid (625mg three times a day for 1 week) for suspected streptococcal pharyngitis. However, her relatives were concerned as the fever and sore throat were not improving despite medications.\nOn examination, the patient was alert and conscious with no signs of respiratory distress. The patient had high fever. Her temperature was 39.8°C. Her general physical examination was normal. On chest examination, bilateral crepitation with bronchial breath sounds was heard. Examination of her cardiovascular system, abdomen and skin were normal. Ear examination showed normal tympanic membrane with no mastoid tenderness bilaterally. On the oral cavity examination, the posterior pharyngeal wall was erythematous with a minimal bulge. The uvula was in midline. There was no evidence of facial nerve palsy nor trismus. On neck examination, tender lymph nodes were palpable in cervical level 1b and 2. Upon physical examination, the left external jugular vein had become a palpable strand with severe tenderness.\nThe blood picture showed a total white blood cell count of 30,930/mm3 with left shift and consisted of 92% neutrophils. The C-reactive protein (CRP) was abnormally elevated (13mg/L). The serum electrolytes were within normal limits. She was a patient of diabetes and her blood glucose control was poor with HbA1C of 12.8. The blood culture was done in Brain Heart Infusion (BHI) broth. It did not show any growth. Lumbar puncture was done but it was negative for meningitis. Urine analysis was negative for any signs of infection. Sputum culture showed Enterobacter species sensitive to gentamicin, meropenem and levofloxacin. X-ray neck anteroposterior and lateral view showed increase in prevertebral shadow at the 4th cervical vertebral region. Cervical lordosis was lost. Diffuse pulmonary infiltrates were present . To rule out deep neck abscess, computed tomography of the neck and chest with intravenous contrast was done. CT scan showed peripheral enhancing collection in the neck in the prevertebral region measuring approximately 10×2 cm and extending from C4 to T3 region. Nasopharynx, oropharynx and hypopharynx appeared normal. The left internal jugular vein showed filling defect extending from the jugular foramen to the common jugular confluence, suggestive for high-grade partial occlusion due to thrombus formation. The cavitary lesion was seen in the left lower lobe of the lung peripherally due to metastatic septic emboli. Bilaterally, multiple nodules were seen in the lung with mild pleural effusion (–).\nThe patient was kept on intravenous meropenem (1gram 8 hourly via intravenous route), metronidazole (500mg 8 hourly via intravenous route) and gentamicin (80mg 8 hourly via intravenous route). The pus in the retropharyngeal space was aspirated by inserting a 10-ml syringe through the oral cavity into the posterior pharyngeal wall. Around 10ml of pus was aspirated. Daily aspiration was done. There was no pus collection on the fourth day. The pus was sent for culture and sensitivity. However, no growth was seen. Anticoagulation therapy with enoxaparin (40mg subcutaneous injection once a day) was also started to the patient. The intravenous antibiotic treatment was given for two weeks. The patient’s condition gradually improved. After two weeks, the patient was discharged on a six weeks course of oral antibiotics and anticoagulation. The antibiotics given were Levofloxacin (500mg once a day) and Clindamycin (300mg three times a day) and the anticoagulant used was warfarin (1mg once a day orally for 6 weeks). On the follow-up visit, the patient was doing well. The patient was followed up to 3 months. She was doing perfectly well.", + "fulltext_subclaims": [ + "The patient was a 70-year-old female.", + "The patient had a sore throat for 7 days.", + "The pain was continuous.", + "The pain radiated to the left ear and the left side of the neck.", + "The pain was aggravated by swallowing both solid and liquid diet.", + "The pain was also aggravated by neck movements.", + "The patient had a severe headache.", + "The patient had neck stiffness.", + "The patient had fever for the same duration.", + "There was no change in the patient's voice.", + "There was no breathing difficulty.", + "The patient was on Amoxycillin-Clavulanic acid (625mg three times a day for 1 week).", + "The patient's relatives were concerned as the fever and sore throat were not improving despite medications.", + "On examination, the patient was alert and conscious.", + "The patient had high fever.", + "Her temperature was 39.8°C.", + "The general physical examination was normal.", + "On chest examination, bilateral crepitation with bronchial breath sounds was heard.", + "Examination of the cardiovascular system, abdomen, and skin were normal.", + "Ear examination showed normal tympanic membrane with no mastoid tenderness bilaterally.", + "On the oral cavity examination, the posterior pharyngeal wall was erythematous with a minimal bulge.", + "The uvula was in midline.", + "There was no evidence of facial nerve palsy nor trismus.", + "On neck examination, tender lymph nodes were palpable in cervical level 1b and 2.", + "The left external jugular vein had become a palpable strand with severe tenderness.", + "The blood picture showed a total white blood cell count of 30,930/mm3 with left shift.", + "The white blood cell count consisted of 92% neutrophils.", + "The C-reactive protein (CRP) was abnormally elevated (13mg/L).", + "The serum electrolytes were within normal limits.", + "She was a patient of diabetes.", + "Her blood glucose control was poor with HbA1C of 12.8.", + "The blood culture was done in Brain Heart Infusion (BHI) broth.", + "The blood culture did not show any growth.", + "Lumbar puncture was done but it was negative for meningitis.", + "Urine analysis was negative for any signs of infection.", + "Sputum culture showed Enterobacter species.", + "The Enterobacter species were sensitive to gentamicin, meropenem, and levofloxacin.", + "X-ray neck anteroposterior and lateral view showed increase in prevertebral shadow at the 4th cervical vertebral region.", + "Cervical lordosis was lost.", + "Diffuse pulmonary infiltrates were present.", + "Computed tomography of the neck and chest with intravenous contrast was done.", + "CT scan showed peripheral enhancing collection in the neck in the prevertebral region measuring approximately 10×2 cm.", + "The collection extended from C4 to T3 region.", + "The left internal jugular vein showed filling defect extending from the jugular foramen to the common jugular confluence.", + "The filling defect was suggestive for high-grade partial occlusion due to thrombus formation.", + "The cavitary lesion was seen in the left lower lobe of the lung peripherally due to metastatic septic emboli.", + "Bilaterally, multiple nodules were seen in the lung with mild pleural effusion.", + "The patient was kept on intravenous meropenem (1gram 8 hourly via intravenous route).", + "The patient was kept on intravenous metronidazole (500mg 8 hourly via intravenous route).", + "The patient was kept on intravenous gentamicin (80mg 8 hourly via intravenous route).", + "The pus in the retropharyngeal space was aspirated by inserting a 10-ml syringe through the oral cavity into the posterior pharyngeal wall.", + "Around 10ml of pus was aspirated.", + "Daily aspiration was done.", + "There was no pus collection on the fourth day.", + "The pus was sent for culture and sensitivity.", + "No growth was seen.", + "Anticoagulation therapy with enoxaparin (40mg subcutaneous injection once a day) was also started.", + "The intravenous antibiotic treatment was given for two weeks.", + "The patient’s condition gradually improved.", + "After two weeks, the patient was discharged on a six weeks course of oral antibiotics and anticoagulation.", + "The antibiotics given were Levofloxacin (500mg once a day) and Clindamycin (300mg three times a day).", + "The anticoagulant used was warfarin (1mg once a day orally for 6 weeks).", + "On the follow-up visit, the patient was doing well.", + "The patient was followed up to 3 months.", + "She was doing perfectly well." + ], + "summary": "A 70-year-old female with retropharyngeal abscess developed features of Lemierre syndrome. The condition was managed with serial aspiration of the abscess and prolonged usage of intravenous antibiotics.", + "summary_subclaims": [ + "The patient is a 70-year-old female.", + "The patient had a retropharyngeal abscess.", + "The patient developed features of Lemierre syndrome.", + "The condition was managed with serial aspiration of the abscess.", + "The condition was managed with prolonged usage of intravenous antibiotics." + ] + }, + { + "id": "multiclinsum_test_2201_en.txt", + "fulltext": "The patient is a 24-year-old right-hand dominant Hispanic female that initially presented to an urgent care office in October 2021 with a right small finger mass on the ulnar aspect of the proximal interphalangeal joint that had been present for several months prior to presentation. She had no pertinent medical or surgical history and a family history positive for renal cell carcinoma and diabetes on her maternal side of the family. She reported the mass would grow and reduce in size, especially during her pregnancy, when at times, she states it would grow to the size of an olive. Her pain worsened after pregnancy, with her newborn child grasping the finger frequently. The urgent care provider attempted aspiration of the mass, which was unsuccessful, and it was diagnosed as a likely ganglion cyst. The patient saw another local hand surgeon sometime after her urgent care visit, with apparent plans to remove the mass that was never executed. In March 2022, the patient presented to the treating hand surgeon with complaints of increasing pain and an open wound with bleeding from the original site of the mass starting one month prior. Plain radiographs demonstrated a soft tissue mass on the ulnar aspect of the small finger near the PIP joint, with some possible small punctate calcifications seen within. The patient underwent a surgical excisional biopsy of the mass on 3/15/22. The surgical pathology was reviewed by two independent pathologists, which was consistent with low-grade leiomyosarcoma of the finger. The immunohistochemical staining and histological slides are seen in . The patient underwent a PET/CT scan in early April 2022 , demonstrating a suspicious lymph node in the right axilla. However, the treating oncologist thought it was benign and likely reactive. This is a clinical and pathologic assessment consistent with AJCC stage 1 A disease. The right small finger mass was also appreciated on the PET/CT scan. A general surgeon was also consulted for a second opinion and felt the lymph node to be benign and reactive.\nGiven the above clinical and imaging findings, in early May 2022, the patient was discussed at the tumor board of the treating hospital, and it was agreed that she would likely get the most benefit from a ray amputation. Routine laboratory studies around this time were unremarkable for any infectious or inflammatory workup. The same day, the patient presented to the treating surgeon's office with a new complaint of another mass, which was more distal on the small finger than the original mass. The exam and radiographs seemed consistent with what was likely another focus of leiomyosarcoma. On 6/15/22, the patient underwent successful right-hand minor finger ray amputation for her primary leiomyosarcoma. The small finger ray was amputated to the level of the mid-metacarpal shaft. The small finger digital nerves also underwent targeted muscle reinnervation. The wound was closed with primary wound closure . The surgical margins assessed by a pathologist were clear for any tumor, with the biopsy results again consistent with low-grade leiomyosarcoma. The patient was followed by her medical oncologist and the hand surgery team as an outpatient over the next several months. Her disease was stable, with the right axillary node showing no sign of change on repeat chest CT scans. The patient's right hand showed no evidence of recurrence or residual tumor clinically or on an MRI of the right hand obtained on 10/11/22. The patient continues progressing well postoperatively and initiated hand therapy approximately three weeks postoperatively. Most recent occupational therapy clinic notes indicated the full function of the right-hand digits 1–4, flexion 0.5 cm from the distal palmar crease, and comparable grip strength to the contralateral hand. She has no pain or other masses. Postoperatively she commented on a prominent and ropy scar, for which she also underwent aggressive therapy and massage . Continued oncologic surveillance and repeat MRI of the right hand showed no local or systemic disease recurrence at nine months postoperatively .", + "fulltext_subclaims": [ + "The patient is a 24-year-old right-hand dominant Hispanic female.", + "She initially presented to an urgent care office in October 2021.", + "She had a right small finger mass on the ulnar aspect of the proximal interphalangeal joint.", + "The mass had been present for several months prior to presentation.", + "She had no pertinent medical or surgical history.", + "Her family history was positive for renal cell carcinoma and diabetes on her maternal side.", + "The mass would grow and reduce in size, especially during her pregnancy.", + "The urgent care provider attempted aspiration of the mass, which was unsuccessful.", + "The mass was diagnosed as a likely ganglion cyst.", + "The patient saw another local hand surgeon sometime after her urgent care visit.", + "Plans to remove the mass were never executed.", + "In March 2022, she presented with complaints of increasing pain and an open wound with bleeding.", + "Plain radiographs demonstrated a soft tissue mass on the ulnar aspect of the small finger near the PIP joint.", + "The patient underwent a surgical excisional biopsy of the mass on 3/15/22.", + "The surgical pathology was reviewed by two independent pathologists.", + "The pathology was consistent with low-grade leiomyosarcoma of the finger.", + "A PET/CT scan in early April 2022 demonstrated a suspicious lymph node in the right axilla.", + "The treating oncologist thought the lymph node was benign and likely reactive.", + "The clinical and pathologic assessment was consistent with AJCC stage 1A disease.", + "The patient was discussed at the tumor board of the treating hospital in early May 2022.", + "It was agreed that she would likely get the most benefit from a ray amputation.", + "The patient presented with a new complaint of another mass on the small finger.", + "The exam and radiographs were consistent with another focus of leiomyosarcoma.", + "On 6/15/22, the patient underwent successful right-hand minor finger ray amputation.", + "The small finger ray was amputated to the level of the mid-metacarpal shaft.", + "The surgical margins assessed by a pathologist were clear for any tumor.", + "The biopsy results were again consistent with low-grade leiomyosarcoma.", + "The patient's right hand showed no evidence of recurrence or residual tumor clinically.", + "An MRI of the right hand obtained on 10/11/22 showed no local or systemic disease recurrence.", + "The patient continued progressing well postoperatively.", + "She initiated hand therapy approximately three weeks postoperatively.", + "Most recent occupational therapy clinic notes indicated full function of the right-hand digits 1–4.", + "She had comparable grip strength to the contralateral hand.", + "She had no pain or other masses.", + "Postoperatively, she commented on a prominent and ropy scar.", + "She underwent aggressive therapy and massage.", + "Continued oncologic surveillance and repeat MRI showed no local or systemic disease recurrence at nine months postoperatively." + ], + "summary": "In this case, we present a young, otherwise healthy patient that was diagnosed with a primary leiomyosarcoma of the small finger. After her diagnosis, she underwent extensive oncologic workup, and subsequently underwent successful ray amputation with an excellent outcome. She remains disease free.", + "summary_subclaims": [ + "The patient was diagnosed with a primary leiomyosarcoma of the small finger.", + "She underwent extensive oncologic workup.", + "She underwent successful ray amputation.", + "She remains disease free." + ] + }, + { + "id": "multiclinsum_test_215_en.txt", + "fulltext": "On 27th July 2020, a 47-year-old woman, working as a ceramic dental technician since November 2018, required a medical examination at our Occupational Health Dept., as in the previous months she was affected by dry and irritating cough, especially related to intense work activity. She also suffered some episodes of low-grade fever and fatigue and dyspnea on efforts. In March 2020, chest CT showed lung nodules characterized by net margins and oval shape, in peripheral or subpleural site, especially in the inferior lobes. The biggest nodule, 9 mm, with polygonal shape, was in the anterior basal segment of the righ inferior lobe .\nPulmonary function tests were in the normality range and revealed a normal diffusing capacity, albeit at the lower limits of the normal (DLCO/VA 73%); autoimmunity markers were in the normal range. Then, she underwent fibro-bronchoscopy with bronchoalveolar lavage (BAL) and bronchial aspirate (BAS). BAL differential cell count showed macrophages (79%), lymphocytes (18%), neutrophil granulocytes (3%), and a CD4/CD8 lymphocyte ratio of 7.8. In both BAL and BAS, several macrophages with numerous intracytoplasmic exogenous metallic material and reflective dust were seen at optical microscopy. Owing to the SARS-CoV2 pandemic, she was absent from workplace from March to August 2020 and in such period her symptoms ameliorated. At work, the woman was involved in milling and polishing monolithic zirconia structures, then layered with ceramic. She described workplace as dusty, lacking aspiration hoods hence she was concerned about workplace safety. She used respiratory personal protective equipment (PPE) inconstantly.\nWe examined three samples of dust settled nearby her workstation by inductively coupled mass spectrometry (ICP-MS) . Among others, we detected average Cobalt (Co), Tungsten (W), Zirconium (Zr) and Yttrium (Y), a component of dental ceramic) at concentrations of 45, 60, 96 and 176 µg/g, respectively. Apart from Co, the same elements could be detected, always by ICP-MS, on a paraffin-embedded BAS sample. On BAL cytocentrifugated slides, scanning electron microscopy (SEM) coupled to Energy Dispersive X-Ray Analysis (EDX) showed numerous inorganic particles, containing Zr and Aluminum (Al), the latter probably as oxide, within the macrophages . In addition, a signal attributed to W was detected but not localized in a specific image detail. About a month after return at work, we investigated metal concentrations in urine (U) and in exhaled breath condensate (EBC), collected either at the beginning and at the end of a workweek, by ICP-MS. We could demonstrate a 6 times weekly increase of urinary concentrations of W (0.18 µg/L vs. 1.1 µg/L). We concluded for a diagnosis of early work-related pneumoconiosis due to abnormal occupational exposure to metals. We advised periodical chest CT and pulmonologist monitoring (the next after 6 months), along with the prescription to strictly wear respiratory personal protective equipment (PPE) at work.", + "fulltext_subclaims": [ + "The patient is a 47-year-old woman.", + "She worked as a ceramic dental technician since November 2018.", + "She had dry and irritating cough related to intense work activity.", + "Chest CT in March 2020 showed lung nodules with net margins and oval shape.", + "The biggest nodule was 9 mm in the anterior basal segment of the right inferior lobe.", + "BAL differential cell count showed macrophages at 79%.", + "BAL differential cell count showed lymphocytes at 18%.", + "BAL differential cell count showed neutrophil granulocytes at 3%.", + "BAL showed macrophages with numerous intracytoplasmic exogenous metallic material.", + "She was absent from work from March to August 2020 due to the SARS-CoV2 pandemic.", + "She was involved in milling and polishing monolithic zirconia structures.", + "The workplace was described as dusty and lacking aspiration hoods.", + "She used respiratory PPE inconstantly.", + "ICP-MS detected average Zirconium at 96 µg/g in dust samples.", + "ICP-MS detected average Yttrium at 176 µg/g in dust samples.", + "SEM-EDX showed inorganic particles containing Zr within macrophages.", + "SEM-EDX showed inorganic particles containing Aluminum within macrophages.", + "A signal attributed to W was detected but not localized in a specific image detail.", + "Urine W concentration increased 6 times weekly after return to work.", + "The diagnosis was early work-related pneumoconiosis due to abnormal occupational exposure to metals.", + "Periodical chest CT and pulmonologist monitoring were advised." + ], + "summary": "We describe the case of an early pneumoconiosis occurring in a 47-year-old dental technician who developed respiratory symptoms shortly after beginning work. She described the work environment as dusty and lacking relevant primary prevention tools. A chest CT showed multiple peripheral pseudonodular lesions in both lower lobes; bronchoalveolar lavage and bronchial aspirate evidenced numerous macrophages with reflective metal bodies included into the cytoplasm, that at scanning electron microscopy coupled to Energy Dispersive X-Ray Analysis resulted Zirconium and Aluminum, whereas Tungsten (W) was localized outside cells. End of shift urinary concentrations of W were substantially raised as compared to pre-shift (1.1 vs. 0.2 µg/L).", + "summary_subclaims": [ + "The patient is a 47-year-old dental technician.", + "She developed respiratory symptoms shortly after beginning work.", + "She described the work environment as dusty.", + "She described the work environment as lacking relevant primary prevention tools.", + "A chest CT showed multiple peripheral pseudonodular lesions in both lower lobes.", + "Bronchoalveolar lavage and bronchial aspirate evidenced numerous macrophages with reflective metal bodies included into the cytoplasm.", + "Scanning electron microscopy coupled to Energy Dispersive X-Ray Analysis resulted Zirconium and Aluminum.", + "Tungsten (W) was localized outside cells.", + "End of shift urinary concentrations of W were substantially raised as compared to pre-shift.", + "End of shift urinary concentrations of W were 1.1 µg/L.", + "Pre-shift urinary concentrations of W were 0.2 µg/L." + ] + }, + { + "id": "multiclinsum_test_3311_en.txt", + "fulltext": "63-year-old male, smoker, hypertensive, presented to the emergency department with a history of left upper motor weakness and a new onset speech articulation disorder at 4:30 a.m. after a previously asymptomatic awakening at 4:00 a.m. with no other associated somatic or neurologic findings. Physical examination was normal and neurologic examination revealed mild dysarthria and a motor balance of 4/5 in the distal region of the left upper limb according to the Medical Research Council Scale of the United Kingdom; the rest of the neurologic examination was normal. He had a National Institute of Health Stroke Scale score of 2.\n\nBlood tests for ion balance, renal and liver function, blood count and coagulation were normal. Cardiological examination with an electrocardiogram and transthoracic echocardiography was normal.\n\nUrgent neuroimaging was performed by cranial computed tomography, which showed a chronic lacunar infarction in the outer capsule and the bilateral lenticular nucleus, and a small hypodensia lesion in the right posteroinferior frontal gyrus of acute chronology. Also, the neurosonological study did not reveal alterations.\n\nThe patient was discharged with the diagnosis of lacunar syndrome of dysarthria-torpe hand in the context of a minor right hemispheric ischemic stroke, clinically LACI (lacunar infarction), of probable hypertensive etiology, and it was decided to discharge him at home with secondary preventive treatment with double antiplatelet aggregation, antihypertensive and statins.\n\nThe patient returned to the emergency department 48 hours later with a sudden onset of pain and hypoesthesia in the left calf and posterior thigh, with no previous history of intermittent claudicatio. Physical examination revealed pallor of the extremity and weakness of the femoral, popliteal, and left lower limb pulses, with the rest of the physical examination normal.\n\nUrgent neuroimaging study was decided to be extended by computed tomography angiography, which excluded extracranial and intracranial stenosis; however, a focal endoluminal replenishment defect was observed in the aortic arch apex with a slightly triangular morphology, occupying 20-30% of the vessel lumen, compatible with a floating thrombus in the aortic arch, with subsequent pathological confirmation. Ultrasound of the left lower limb showed absence of arterial and venous Doppler in the anterior tibial/posterior tibial region, without popliteal arterial Doppler signal and evidence of terminal embolism in the common femoral artery bifurcation, as well as in the origin of the superficial femoral artery and the deep femoral artery.\n\nThe patient was diagnosed with acute ischemic syndrome of the left lower extremity and a transfemoral embolectomy was performed. He was discharged with therapeutic doses of enoxaparin and dual antiplatelet therapy due to the embologenic mechanism.\n\nHowever, he returned to the emergency room a third time 24 hours later with pain and numbness in the right upper limb. Vascular examination revealed a right humeral rebound pulse with no distal pulses, and ultrasound showed thrombi in the bifurcation of the brachial artery and in the radial artery. He was diagnosed with acute ischemic syndrome of the right upper limb and a transhumeral embolectomy was performed. Finally, in the follow-up computed tomography angiography performed one month later, the floating thrombus disappeared and anticoagulation was optimized.\n", + "fulltext_subclaims": [ + "The patient is a 63-year-old male.", + "He is a smoker.", + "He has hypertension.", + "He presented with left upper motor weakness.", + "He had a new onset speech articulation disorder at 4:30 a.m.", + "He awoke at 4:00 a.m. with no other associated somatic or neurologic findings.", + "Physical examination was normal.", + "Neurologic examination revealed mild dysarthria.", + "Neurologic examination showed a motor balance of 4/5 in the distal region of the left upper limb.", + "The motor balance was assessed using the Medical Research Council Scale of the United Kingdom.", + "The rest of the neurologic examination was normal.", + "He had a National Institute of Health Stroke Scale score of 2.", + "Blood tests for ion balance, renal and liver function, blood count, and coagulation were normal.", + "Cardiological examination with an electrocardiogram and transthoracic echocardiography was normal.", + "Urgent neuroimaging was performed by cranial computed tomography.", + "Cranial computed tomography showed a chronic lacunar infarction in the outer capsule.", + "Cranial computed tomography showed chronic lacunar infarctions in the bilateral lenticular nucleus.", + "Cranial computed tomography showed a small hypodensia lesion in the right posteroinferior frontal gyrus.", + "The hypodensia lesion was of acute chronology.", + "The neurosonological study did not reveal alterations.", + "The patient was discharged with the diagnosis of lacunar syndrome of dysarthria-torpe hand.", + "The diagnosis was in the context of a minor right hemispheric ischemic stroke.", + "The diagnosis was clinically LACI (lacunar infarction).", + "The stroke was of probable hypertensive etiology.", + "The patient was discharged at home with secondary preventive treatment.", + "Secondary preventive treatment included double antiplatelet aggregation.", + "Secondary preventive treatment included antihypertensive medication.", + "Secondary preventive treatment included statins.", + "The patient returned to the emergency department 48 hours later.", + "He had a sudden onset of pain and hypoesthesia in the left calf and posterior thigh.", + "He had no previous history of intermittent claudicatio.", + "Physical examination revealed pallor of the left extremity.", + "Physical examination showed weakness of the femoral, popliteal, and left lower limb pulses.", + "Urgent neuroimaging was extended by computed tomography angiography.", + "Computed tomography angiography excluded extracranial and intracranial stenosis.", + "Computed tomography angiography showed a focal endoluminal replenishment defect in the aortic arch apex.", + "The defect had a slightly triangular morphology.", + "The defect occupied 20-30% of the vessel lumen.", + "The defect was compatible with a floating thrombus in the aortic arch.", + "Pathological confirmation was obtained.", + "Ultrasound of the left lower limb showed absence of arterial and venous Doppler in the anterior tibial/posterior tibial region.", + "Ultrasound showed no popliteal arterial Doppler signal.", + "Ultrasound showed evidence of terminal embolism in the common femoral artery bifurcation.", + "Ultrasound showed terminal embolism in the origin of the superficial femoral artery.", + "Ultrasound showed terminal embolism in the deep femoral artery.", + "The patient was diagnosed with acute ischemic syndrome of the left lower extremity.", + "A transfemoral embolectomy was performed.", + "He was discharged with therapeutic doses of enoxaparin.", + "He was discharged with dual antiplatelet therapy due to the embologenic mechanism.", + "He returned to the emergency room a third time 24 hours later.", + "He had pain and numbness in the right upper limb.", + "Vascular examination revealed a right humeral rebound pulse with no distal pulses.", + "Ultrasound showed thrombi in the bifurcation of the brachial artery.", + "Ultrasound showed thrombi in the radial artery.", + "He was diagnosed with acute ischemic syndrome of the right upper limb.", + "A transhumeral embolectomy was performed.", + "In the follow-up computed tomography angiography performed one month later, the floating thrombus disappeared.", + "Anticoagulation was optimized." + ], + "summary": "We present the case of a 63-year-old hypertensive man with dysarthria-clumsy hand syndrome due to a right hemispheric minor ischemic stroke. The patient developed a sequential acute lower left and upper right limb thromboembolism. Computed tomography angiography revealed a thrombus in the aortic arch. Vascular surgery was performed successfully.\n", + "summary_subclaims": [ + "The patient is a 63-year-old man.", + "The patient is hypertensive.", + "The patient had dysarthria-clumsy hand syndrome.", + "The dysarthria-clumsy hand syndrome was due to a right hemispheric minor ischemic stroke.", + "The patient developed acute lower left limb thromboembolism.", + "The patient developed acute upper right limb thromboembolism.", + "Computed tomography angiography revealed a thrombus in the aortic arch.", + "Vascular surgery was performed." + ] + }, + { + "id": "multiclinsum_test_1468_en.txt", + "fulltext": "A 59- year-old female was admitted at our Unit of Neurosurgery with a 4-month history of progressive and severe dorsal back pain without neurological signs. The patient had been previously surgically treated in 2007, 2011, and 2013 for a recidivated MCC in the occipital region, firstly mistaken for a basal cell carcinoma. The resection had been followed by several cycles of chemotherapy (5-fluorouracil and cisplatin) and local radiotherapy. In the last surgical excision, a lateral cervical lymph node dissection had been performed. The patient had no other comorbidities or any other cancer and she was not immunocompromised. Two years later, the patient complained the onset of progressive pain in the dorsal region. After the admission at our Unit, a Magnetic Resonance Imaging (MRI) with gadolinium contrast medium of the dorsal spine was performed. A neoplastic involvement of two vertebral bodies (T7 and T8) was visible on the contrast-enhanced T1-weighted images , a local cord impingement and a segmental local kyphosis were visible on T2-weighted images , while and an osteolytic shape was visible on Short-T1 Inversion Recovery (STIR) sequence . A total body computed tomography (CT) showed several lungs and liver metastases. Neurologic examination was unremarkable. A multidisciplinary consultation was performed, a palliative surgery was decided and the patient was operated employing a posterior dorsal approach based on the use of radiofrequency (RF) thermoablation (MetaSTAR, Dfine, San Jose, USA), followed by the injection of polymethyl methacrylate (PMMA) in T7 and T8 vertebral body and a transpedicle fixation T5-T9. The histopathological analysis of the vertebral body biopsy confirmed that the metastasis is derived from the MCC. Postoperative MRI showed a reduction of the neoplastic volume in both involved vertebral bodies (T7 and T8) [Figure and ], while a thoracic CT scan revealed the improvement of the segmental thoracic curvature with correct pedicle fixation and a partial vertebral augmentation [Figure and ]. The postoperative course was uneventful and there was a significant reduction of dorsal pain. The patient is still alive after 8 months, in good general conditions and is going through chemo and radiotherapy.", + "fulltext_subclaims": [ + "The patient is a 59-year-old female.", + "She was admitted to the Unit of Neurosurgery.", + "She had a 4-month history of progressive and severe dorsal back pain.", + "She had no neurological signs.", + "She had been previously surgically treated in 2007, 2011, and 2013.", + "The surgical treatment was for a recidivated MCC in the occipital region.", + "The MCC was initially mistaken for a basal cell carcinoma.", + "The resection was followed by several cycles of chemotherapy (5-fluorouracil and cisplatin).", + "The resection was followed by local radiotherapy.", + "In the last surgical excision, a lateral cervical lymph node dissection had been performed.", + "The patient had no other comorbidities.", + "The patient had no other cancer.", + "She was not immunocompromised.", + "Two years later, she complained of the onset of progressive pain in the dorsal region.", + "A Magnetic Resonance Imaging (MRI) with gadolinium contrast medium of the dorsal spine was performed.", + "A neoplastic involvement of two vertebral bodies (T7 and T8) was visible on the contrast-enhanced T1-weighted images.", + "A local cord impingement was visible on T2-weighted images.", + "A segmental local kyphosis was visible on T2-weighted images.", + "An osteolytic shape was visible on Short-T1 Inversion Recovery (STIR) sequence.", + "A total body computed tomography (CT) showed several lungs and liver metastases.", + "Neurologic examination was unremarkable.", + "A multidisciplinary consultation was performed.", + "A palliative surgery was decided.", + "The patient was operated employing a posterior dorsal approach.", + "The approach was based on the use of radiofrequency (RF) thermoablation (MetaSTAR, Dfine, San Jose, USA).", + "Polymethyl methacrylate (PMMA) was injected in T7 and T8 vertebral body.", + "A transpedicle fixation T5-T9 was performed.", + "The histopathological analysis of the vertebral body biopsy confirmed that the metastasis is derived from the MCC.", + "Postoperative MRI showed a reduction of the neoplastic volume in both involved vertebral bodies (T7 and T8).", + "A thoracic CT scan revealed the improvement of the segmental thoracic curvature.", + "The thoracic CT scan showed correct pedicle fixation.", + "The thoracic CT scan showed partial vertebral augmentation.", + "The postoperative course was uneventful.", + "There was a significant reduction of dorsal pain.", + "The patient is still alive after 8 months.", + "The patient is in good general conditions.", + "The patient is going through chemo and radiotherapy." + ], + "summary": "A 59-year-old woman was admitted at our Unit of Neurosurgery with a 4-month history of progressive and severe dorsal back pain, without neurological signs. The patient had been surgically treated for a recidivated MCC in the occipital region in 2007, 2011, and 2013. (In 2013, the surgical treatment also included lateral cervical lymph node dissection). Chemotherapy and radiotherapy had come after the treatments. Magnetic resonance imaging (MRI) of the dorsal spine showed metastatic vertebral involvement with cord impingement of the T7-T8 levels. A total body CT scan revealed lungs and liver metastases, besides vertebral district. After a multidisciplinary consult a palliative surgery was decided and a posterior dorsal approach was employed: Radiofrequency (RF) thermoablation was followed by the injection of cement of T7 and T8 and transpedicle fixation T5-T9. The postoperative course was uneventful and followed by a further adjuvant therapy.", + "summary_subclaims": [ + "The patient was a 59-year-old woman.", + "She was admitted at the Unit of Neurosurgery.", + "She had a 4-month history of progressive and severe dorsal back pain.", + "She had no neurological signs.", + "The patient had been surgically treated for a recidivated MCC in the occipital region in 2007.", + "The patient had been surgically treated for a recidivated MCC in the occipital region in 2011.", + "The patient had been surgically treated for a recidivated MCC in the occipital region in 2013.", + "In 2013, the surgical treatment also included lateral cervical lymph node dissection.", + "Chemotherapy had come after the treatments.", + "Radiotherapy had come after the treatments.", + "Magnetic resonance imaging (MRI) of the dorsal spine showed metastatic vertebral involvement with cord impingement of the T7-T8 levels.", + "A total body CT scan revealed lungs and liver metastases.", + "A total body CT scan revealed vertebral district metastases.", + "After a multidisciplinary consult, a palliative surgery was decided.", + "A posterior dorsal approach was employed.", + "Radiofrequency (RF) thermoablation was performed.", + "Cement was injected into T7 and T8.", + "Transpedicle fixation T5-T9 was performed.", + "The postoperative course was uneventful.", + "The patient was followed by a further adjuvant therapy." + ] + }, + { + "id": "multiclinsum_test_2902_en.txt", + "fulltext": "An 83-year-old woman slipped and fell, complaining of the left hip pain and was unable to bear weight. She referred she was submitted to a hip arthrodesis 53 years ago, after an undiagnosed congenital hip dislocation. She also suffered from poliomyelitis and walked around with a cane. The radiographic and tomographic evaluation showed an intertrochanteric fracture in a long-lasting ankylosed hip ( and ). After carefully assessing scientific evidence and discussing the appropriate treatment strategy, the patient was prepared for surgery. She was positioned in lateral decubitus and a lateral approach was used, centered on the great trochanter. The fracture was exposed and fixated with two plates. One proximal locking femoral plate, with 6mm×4.5 mm cortical and 4mm×6.5 mm cannulated screws, was applied to the head and proximal femur. Expecting a great stress in the fracture site, this construction was reinforced with a 3.5 mm pelvic reconstruction plate, with 8mm×3.5 mm cortical screws, spanning from the iliac wing to the proximal femur ( and ). Due to the poor bone quality and the unusual long lever arm, the patient was not permitted to walk until 3weeks after the intervention and only partial weight-bearing afterward. Bone healing occurred after 3months, allowing the patient to walk with a single cane and full weight-bearing .", + "fulltext_subclaims": [ + "The patient is an 83-year-old woman.", + "She slipped and fell.", + "She complained of left hip pain.", + "She was unable to bear weight.", + "She referred she was submitted to a hip arthrodesis 53 years ago.", + "The hip arthrodesis was after an undiagnosed congenital hip dislocation.", + "She also suffered from poliomyelitis.", + "She walked around with a cane.", + "The radiographic and tomographic evaluation showed an intertrochanteric fracture.", + "The fracture was in a long-lasting ankylosed hip.", + "The patient was prepared for surgery.", + "She was positioned in lateral decubitus.", + "A lateral approach was used, centered on the great trochanter.", + "The fracture was exposed and fixated with two plates.", + "One proximal locking femoral plate was applied to the head and proximal femur.", + "The proximal locking femoral plate had 6mm×4.5 mm cortical and 4mm×6.5 mm cannulated screws.", + "The construction was reinforced with a 3.5 mm pelvic reconstruction plate.", + "The 3.5 mm pelvic reconstruction plate had 8mm×3.5 mm cortical screws.", + "The plate spanned from the iliac wing to the proximal femur.", + "The patient was not permitted to walk until 3 weeks after the intervention.", + "The patient was only allowed partial weight-bearing afterward.", + "Bone healing occurred after 3 months.", + "The patient was able to walk with a single cane.", + "The patient was allowed full weight-bearing." + ], + "summary": "A Caucasian 83-year-old woman slipped and fell, complaining of the left hip pain. After radiographic evaluation, she was diagnosed with an intertrochanteric fracture that occurred in a long-term arthrodesed hip. We treated this rare presentation by open reduction and internal fixation with a proximal locking femoral plate and a pelvic reconstruction plate. No immobilization was needed in the post-operative care. Fracture healing occurred after 3months.", + "summary_subclaims": [ + "The patient is an 83-year-old woman.", + "She slipped and fell.", + "She complained of left hip pain.", + "Radiographic evaluation was performed.", + "She was diagnosed with an intertrochanteric fracture.", + "The fracture occurred in a long-term arthrodesed hip.", + "The treatment was open reduction and internal fixation.", + "A proximal locking femoral plate was used.", + "A pelvic reconstruction plate was used.", + "No immobilization was needed in the post-operative care.", + "Fracture healing occurred after 3 months." + ] + }, + { + "id": "multiclinsum_test_1393_en.txt", + "fulltext": "A 19-year-old female was evaluated at the Department of Adult Psychiatry Outpatient Clinic with complaints of lack of enjoyment of pleasurable activities, sleep disturbances, suicidal thoughts, and self-induced injury at times of high stress via superficial cutting behaviors on her forearms. These symptoms were in association with ongoing family conflict with her mother and her sister with whom she lived.\nAt the psychiatric evaluation, she expressed that her self-esteem was strongly affected by her turbulent family relationships, and she seemed extremely unhappy. She reported superficial cutting behaviors at least 2 times a week, usually in an impulsive fashion. Laboratory evaluations including hemogram, liver function tests, total protein, vitamin B12, folic acid, T3, T4, and TSH were within normal limits. Baseline psychiatric evaluation with the Beck Depression Inventory (BDI-II) revealed scores of 21 (moderate depression) . According to clinical evaluation as well as DSM-V criteria, the patient was diagnosed with major depressive disorder and borderline personality disorder, and she was started on citalopram 20 mg by mouth per day . Cognitive behavioral therapy focusing on negative cognitions was also initiated. Partial response to treatment was observed at the 12th week with reduction of BDI-II score to 12 (mild mood disturbance).\nWhile she was under follow-up at the Department of Adult Psychiatry Outpatient Clinic, she admitted to a prior ingestion of a portion of a small bottle (less than 30 milliliters per her description of the product packaging) of a commercially available chemical skin exfoliator containing TCAA. This consumption was impulsive per her description and occurred after an argument with her mother. While such products available over the counter can typically range from 8% to 30% TCAA ingredient which determines strength, she did not recall what percentage of TCAA was in the product . She had purchased the TCAA peel to brighten and even out her skin tone by reducing the appearance of hyperpigmentation (acne marks and freckles). She believed the product to also contain antidepressant TCA, since the product was marketed per her report as a “TCA peel,” which is often done in the industry. She knew that TCA antidepressants can be extremely damaging or even fatal in overdose which was her intent. TCA effects in overdose are well documented in the literature . Her symptoms after ingestion were burning pain on her lips and in her mouth, which frightened her somewhat, preventing her from consuming more of the product. She also complained at the time of mild abdominal discomfort followed by an episode of vomiting. Fortunately no other symptoms were reported and all of the symptoms resolved within a few hours. She was asymptomatic at the time of reporting this event to the outpatient clinic.", + "fulltext_subclaims": [ + "The patient is a 19-year-old female.", + "She was evaluated at the Department of Adult Psychiatry Outpatient Clinic.", + "She reported lack of enjoyment of pleasurable activities.", + "She reported sleep disturbances.", + "She reported suicidal thoughts.", + "She reported self-induced injury at times of high stress via superficial cutting behaviors on her forearms.", + "These symptoms were in association with ongoing family conflict with her mother and her sister.", + "She expressed that her self-esteem was strongly affected by her turbulent family relationships.", + "She reported superficial cutting behaviors at least 2 times a week.", + "She reported that the cutting behaviors were usually in an impulsive fashion.", + "Laboratory evaluations including hemogram, liver function tests, total protein, vitamin B12, folic acid, T3, T4, and TSH were within normal limits.", + "Baseline psychiatric evaluation with the Beck Depression Inventory (BDI-II) revealed scores of 21.", + "The patient was diagnosed with major depressive disorder.", + "The patient was diagnosed with borderline personality disorder.", + "She was started on citalopram 20 mg by mouth per day.", + "Cognitive behavioral therapy focusing on negative cognitions was initiated.", + "Partial response to treatment was observed at the 12th week.", + "The BDI-II score reduced to 12 at the 12th week.", + "She admitted to a prior ingestion of less than 30 milliliters of a commercially available chemical skin exfoliator containing TCAA.", + "The ingestion occurred after an argument with her mother.", + "She believed the product to also contain antidepressant TCA.", + "She knew that TCA antidepressants can be extremely damaging or even fatal in overdose.", + "Her intent was to consume the TCA in overdose.", + "She experienced burning pain on her lips and in her mouth after ingestion.", + "She had mild abdominal discomfort followed by an episode of vomiting.", + "All of the symptoms resolved within a few hours.", + "She was asymptomatic at the time of reporting this event to the outpatient clinic." + ], + "summary": "A patient ingested TCAA in the form of a commercially available dermatological chemical peel as a self-harm attempt, thinking that it was a more injurious TCA.", + "summary_subclaims": [ + "A patient ingested TCAA in the form of a commercially available dermatological chemical peel.", + "The ingestion was a self-harm attempt.", + "The patient thought that it was a more injurious TCA." + ] + }, + { + "id": "multiclinsum_test_704_en.txt", + "fulltext": "A 2630 g female newborn was delivered at term by a cesarean section due to deceleration after an uncomplicated pregnancy to a 36-year-old mother. Since the age of three months she was hospitalized several times with intermittent wheezing, inspiratory stridor, epigastrical retractions, dyspnea and cough. Each time, she was diagnosed either with bronchiolitis or wheezy bronchitis and treated with bronchodilators, inhaled corticosteroids and antibiotics. However the symptoms recurred frequently, therefore further diagnostic approaches were initiated including chest-radiography, allergy tests (specific IgE) and otorhinolaryngeal examination, which revealed no abnormalities. At the age of two years the girl was admitted to our hospital because of an acute exacerbation of her pulmonary situation. She presented in reduced physical condition with respiratory distress at rest, wheezing and dry cough. Inhalation therapy with beta agonists showed no success, there were no signs of a severe viral or bacterial infection. Based on her medical history of several episodes with recurrent, therapy-refractory wheezing without signs of an infection and her acute condition of severe respiratory distress we decided to extend the diagnostic approach and underwent flexible bronchoscopy under general anesthesia. The larynx appeared with a mild malacia, the branching of the right upper lobe bronchus (RUL) was atypical in the anterior aspect of the carina followed by tracheal stenosis. The main bronchi could not be entered with a two millimeter bronchoscope . Therefore and to identify the exact anatomical situation a CT scan of the lung was performed with a three-dimensional reconstruction of the tracheo-bronchial system, which demonstrated a voluminous right upper lobe bronchus branching of the trachea at the level of the aortic arch, followed distally by a tracheal stenosis to the left . At a lower vertebral level than that of the normal carina (T5-6), the trachea was divided into two bronchi (bifurcatio tracheae), of which one proceeded to the left side of the lung (left main bronchus, LMB) and one adjacently with the pulmonary artery to the right (bridging bronchus, BB). This bridging bronchus upcoming from the left supplied the right lower and middle lobe. Whereas the right lower lobe was normally configured, the right middle lobe appeared hypoplastic. Parts of the ventral upper lobe were hyperinflated. Despite the small diameter of the left main bronchus, the left lung was normally ventilated. CT scan provided no indication of an associated vascular malformation e.g. a left sling pulmonary artery (SLPA). To exclude further anatomical variations of the cardiovascular, renal or gastrointestinal system echocardiography and abdominal ultrasound were performed and demonstrated no anomalies.\nTreatment with epinephrine inhalation and leucotriene receptor antagonist was initiated for several weeks and the patient was followed by our outpatient clinics every three months. Early intervention with physiotherapy, early use of mucolytic therapy and antibiotics were recommended during infections. During her three-years follow up period the girl has shown several croup-like attacks, but did well without further intervention or therapy.", + "fulltext_subclaims": [ + "The patient is a 2630 g female newborn delivered at term by cesarean section.", + "The cesarean section was performed due to deceleration.", + "The pregnancy was uncomplicated.", + "The mother is 36 years old.", + "The patient was hospitalized several times since the age of three months.", + "Each hospitalization was due to intermittent wheezing, inspiratory stridor, epigastrical retractions, dyspnea, and cough.", + "Each time, she was diagnosed with bronchiolitis or wheezy bronchitis.", + "Each time, she was treated with bronchodilators, inhaled corticosteroids, and antibiotics.", + "The symptoms recurred frequently.", + "Further diagnostic approaches were initiated.", + "Chest-radiography, allergy tests (specific IgE), and otorhinolaryngeal examination revealed no abnormalities.", + "At the age of two years, the girl was admitted to our hospital due to an acute exacerbation of her pulmonary situation.", + "She presented in reduced physical condition with respiratory distress at rest, wheezing, and dry cough.", + "Inhalation therapy with beta agonists showed no success.", + "There were no signs of a severe viral or bacterial infection.", + "Based on her medical history of several episodes with recurrent, therapy-refractory wheezing without signs of an infection and her acute condition of severe respiratory distress, we decided to extend the diagnostic approach.", + "Flexible bronchoscopy under general anesthesia was performed.", + "The larynx appeared with a mild malacia.", + "The branching of the right upper lobe bronchus (RUL) was atypical in the anterior aspect of the carina.", + "The branching of the RUL was followed by tracheal stenosis.", + "The main bronchi could not be entered with a two millimeter bronchoscope.", + "A CT scan of the lung with three-dimensional reconstruction of the tracheo-bronchial system was performed.", + "The CT scan demonstrated a voluminous right upper lobe bronchus branching off the trachea at the level of the aortic arch.", + "The CT scan demonstrated a tracheal stenosis to the left.", + "The trachea was divided into two bronchi at a lower vertebral level than that of the normal carina (T5-6).", + "One bronchus proceeded to the left side of the lung (left main bronchus, LMB).", + "One bronchus proceeded adjacently with the pulmonary artery to the right (bridging bronchus, BB).", + "The bridging bronchus supplied the right lower and middle lobe.", + "The right lower lobe was normally configured.", + "The right middle lobe appeared hypoplastic.", + "Parts of the ventral upper lobe were hyperinflated.", + "Despite the small diameter of the left main bronchus, the left lung was normally ventilated.", + "The CT scan provided no indication of an associated vascular malformation, e.g., a left sling pulmonary artery (SLPA).", + "Echocardiography and abdominal ultrasound were performed.", + "Echocardiography and abdominal ultrasound demonstrated no anomalies.", + "Treatment with epinephrine inhalation and leucotriene receptor antagonist was initiated for several weeks.", + "The patient was followed by our outpatient clinics every three months.", + "Early intervention with physiotherapy, early use of mucolytic therapy, and antibiotics were recommended during infections.", + "During her three-years follow-up period, the girl has shown several croup-like attacks.", + "The girl did well without further intervention or therapy." + ], + "summary": "We report about an infant with recurrent episodes of wheezy bronchitis, which persisted despite adequate therapy. Bronchoscopy and computed tomography of the lung with three-dimensional reconstruction revealed a rare bronchial branching anomaly - the so called \"bridging bronchus\". In contrast to previous case reports, this infant showed no additional malformations, which seems to be important for the prognosis.", + "summary_subclaims": [ + "The infant had recurrent episodes of wheezy bronchitis.", + "The wheezy bronchitis persisted despite adequate therapy.", + "Bronchoscopy and computed tomography of the lung with three-dimensional reconstruction were performed.", + "A rare bronchial branching anomaly was found.", + "The anomaly was described as a 'bridging bronchus'.", + "The infant showed no additional malformations.", + "The absence of additional malformations seems to be important for the prognosis." + ] + }, + { + "id": "multiclinsum_test_2463_en.txt", + "fulltext": "An 82-year-old white man with a medical history of paroxysmal atrial fibrillation for which coumarins were prescribed presented with an episode of macroscopic hematuria. A physical rectal examination revealed a diffusely indurated prostate and computed tomography (CT) showed normal aspect of his kidneys and bladder as well as an enlarged prostate. Laboratory analysis showed a white blood cell count within normal limits (6.69×109/L) and a slight increase in prostate-specific antigen from 4 to 9.4 ng/ml. A transrectal US of his prostate revealed a hypoechoic and hypervascular subcapsular area in the peripheral zone of his prostate with a differential diagnosis including diffuse carcinoma or granulomatous inflammation. An uneventful US-guided transrectal biopsy was performed on an out-patient basis, 7 days after anticoagulation therapy was ceased. Pathologic analysis of the biopsy specimen revealed a diffuse carcinoma of the peripheral zone of his prostate. Three days later, a massive rectal hemorrhage occurred, associated with hemodynamic shock (blood pressure 50/30 mmHg, heart rate 100 beats per minute). A good hemodynamic response was obtained after appropriate therapeutic management. A clinical examination revealed a nodular rectal area in the prostate bed without a large hematoma. Endoscopy revealed two active arterial bleeders in his lower rectum but endoscopic clipping failed. He was referred to the angiography suite for emergency interventional treatment. Selective angiography of his inferior mesenteric artery did not reveal any bleeding. Selective catheterization of the anterior division of his right internal iliac artery revealed a prostatic artery with an inferior and superior branch. With a microcatheter (Progreat 2.7, Terumo Europe, Leuven, Belgium), selective catheterization of his internal pudendal artery revealed an arteriovenous fistula (AVF) in the left prostatic body, fed from collaterals originating from his right inferior prostatic artery . No contrast extravasation was noted. Embolization with calibrated microparticles (Embosphere® 300–500 μ, Merit Medical, South Jordan, Utah, USA) was performed, followed by placement of three 4×4 mm microcoils (Target®, Boston Scientific Inc Natick, MA, USA) at the origin of the anastomosis with his left inferior prostatic artery . Control angiography following embolization showed complete occlusion of the treated artery without residual opacification of the AVF. Selective angiography of his left internal iliac artery showed a patent internal pudendal artery with normal opacification of his dorsal penile artery and without opacification of an AVF . He was discharged the next day without clinical signs of postembolization syndrome or lower urinary tract symptoms.", + "fulltext_subclaims": [ + "The patient is an 82-year-old white man.", + "The patient has a medical history of paroxysmal atrial fibrillation.", + "Coumarins were prescribed for the patient's atrial fibrillation.", + "The patient presented with an episode of macroscopic hematuria.", + "A physical rectal examination revealed a diffusely indurated prostate.", + "Computed tomography showed an enlarged prostate.", + "Laboratory analysis showed a white blood cell count within normal limits.", + "The prostate-specific antigen increased from 4 to 9.4 ng/ml.", + "A transrectal US of the prostate revealed a hypoechoic and hypervascular subcapsular area in the peripheral zone.", + "The differential diagnosis included diffuse carcinoma or granulomatous inflammation.", + "An uneventful US-guided transrectal biopsy was performed.", + "The biopsy was performed 7 days after anticoagulation therapy was ceased.", + "Pathologic analysis of the biopsy specimen revealed a diffuse carcinoma of the peripheral zone of the prostate.", + "Three days after the biopsy, a massive rectal hemorrhage occurred.", + "The hemorrhage was associated with hemodynamic shock.", + "A good hemodynamic response was obtained after appropriate therapeutic management.", + "Endoscopy revealed two active arterial bleeders in the lower rectum.", + "Endoscopic clipping failed.", + "Selective angiography of the inferior mesenteric artery did not reveal any bleeding.", + "Selective catheterization of the anterior division of the right internal iliac artery revealed a prostatic artery with an inferior and superior branch.", + "Selective catheterization of the internal pudendal artery revealed an arteriovenous fistula in the left prostatic body.", + "The AVF was fed from collaterals originating from the right inferior prostatic artery.", + "Embolization with calibrated microparticles was performed.", + "Three microcoils were placed at the origin of the anastomosis with the left inferior prostatic artery.", + "Control angiography showed complete occlusion of the treated artery.", + "The patient was discharged the next day without clinical signs of postembolization syndrome.", + "The patient was discharged without lower urinary tract symptoms." + ], + "summary": "We report the case of an 82-year-old white man presenting with massive rectal bleeding after ultrasound-guided prostatic biopsy. Medical and endoscopic management were not effective. Angiographic evaluation revealed a prostatic arteriovenous fistula, and definitive treatment was provided in the form of catheter-directed superselective embolotherapy.", + "summary_subclaims": [ + "The patient was an 82-year-old white man.", + "The patient presented with massive rectal bleeding.", + "The rectal bleeding occurred after ultrasound-guided prostatic biopsy.", + "Medical and endoscopic management were not effective.", + "Angiographic evaluation revealed a prostatic arteriovenous fistula.", + "Definitive treatment was provided in the form of catheter-directed superselective embolotherapy." + ] + }, + { + "id": "multiclinsum_test_30_en.txt", + "fulltext": "A 72-year-old male with a history of lung cancer, with left lower lung lobectomy and right upper lobe wedge resection, chronic obstructive pulmonary disease, and atrial fibrillation presented with 2 weeks duration of fever, cough, shortness of breath, and poor appetite. Nine days before admission, he tested positive for COVID-19 by a real-time polymerase chain reaction. He had a 60-pack-year smoking history. At home, he was taking 81 mg of aspirin once daily, 20 mg of rivaroxaban once daily, 40 mg of atorvastatin once daily, 40 mg of furosemide once daily, and albuterol 90 μg/actuation inhaler, which were continued while he was hospitalized.\nDuring his first hour of admission, he required 2 L/min of supplemental oxygen to maintain adequate saturation, although the rest of his vitals were stable. Laboratory test results were significant for the following: C-reactive protein 304.87 mg/L (0–10 mg/L); lactate 3.2 mEq/L (0.2–1.9 mEq/L); lactate dehydrogenase 659 U/L (100–220 IU/L); d dimer 2374 ng/mL (0–300 ng/mL); aspartate transaminase 45 U/L; and alanine transaminase 36 U/L (6–45 IU/L). Venous blood gas revealed pH 7.46 (7.32–7.42), pCO2 39 mmHg (42–50 mmHg), and pO2 34 mmHg (30–50 mmHg). The chest radiograph demonstrated bilateral patchy airspace disease. Electrocardiogram (ECG) demonstrated atrial fibrillation and right bundle branch block (RBBB). QRS interval was 132 ms . Within 3 h of presentation, the QRS complexes reverted to narrow complexes. Hence, he was in intermittent RBBB.\nRemdesivir was started on Day 1 of his hospitalization, with a loading dose of 200 mg on Day 1 and 100 mg daily for four additional days. He was started on Dexamethasone 6 mg daily for 10 days. Within 24 h of initiation of Remdesivir, he was noted to be in atrial fibrillation with slow ventricular rates between 30 and 40 b.p.m. He was also requiring 40 L/min of oxygen through a high flow nasal cannula and subsequently transferred to the intensive care unit. Two sets of troponins I were 0.028 and 0.022 ng/mL (0.03–0.04 ng/mL).\nOn Day 5 of Remdesivir therapy, he was noted to be persistently bradycardic. ECG demonstrated atrial fibrillation with slow, fixed ventricular response, consistent with complete atrioventricular (AV) block . Echocardiography done on that day showed an ejection fraction of 60% with moderate pulmonary hypertension, dilated right ventricle, mild aortic insufficiency, moderate tricuspid insufficiency, and mildly reduced right ventricular function.\nHaving completed the Remdesivir regimen, during the next 48 h, he was closely monitored, and the AV block resolved spontaneously. ECG done on Day 10 demonstrated atrial fibrillation with ventricular rates between 52 and 58 b.p.m. . He was noted to be clinically improving, with his supplemental oxygen requirements decreasing from 40 to 15 L/min. As he remained asymptomatic and had an adequate chronotropic response with activity, pacemaker implantation was not recommended. Over the next 2 weeks, his oxygen requirements improved, and his heart rate remained between 48 and 60 b.p.m. He was discharged home after a 3-week stay in the hospital on 2 L/min of supplemental oxygen.\nHe died ∼2 weeks after being discharged from the hospital. The cause of his death was not known.", + "fulltext_subclaims": [ + "The patient is a 72-year-old male.", + "He has a history of lung cancer.", + "He had a left lower lung lobectomy.", + "He had a right upper lobe wedge resection.", + "He has chronic obstructive pulmonary disease.", + "He has atrial fibrillation.", + "He presented with 2 weeks of fever.", + "He presented with 2 weeks of cough.", + "He presented with 2 weeks of shortness of breath.", + "He presented with 2 weeks of poor appetite.", + "Nine days before admission, he tested positive for COVID-19 by real-time polymerase chain reaction.", + "He had a 60-pack-year smoking history.", + "At home, he was taking 81 mg of aspirin once daily.", + "At home, he was taking 20 mg of rivaroxaban once daily.", + "At home, he was taking 40 mg of atorvastatin once daily.", + "At home, he was taking 40 mg of furosemide once daily.", + "At home, he was using an albuterol 90 μg/actuation inhaler.", + "These medications were continued while he was hospitalized.", + "During his first hour of admission, he required 2 L/min of supplemental oxygen.", + "C-reactive protein was 304.87 mg/L.", + "Lactate was 3.2 mEq/L.", + "Lactate dehydrogenase was 659 U/L.", + "D-dimer was 2374 ng/mL.", + "Venous blood gas revealed pH 7.46.", + "Venous blood gas revealed pCO2 39 mmHg.", + "Venous blood gas revealed pO2 34 mmHg.", + "The chest radiograph demonstrated bilateral patchy airspace disease.", + "The ECG demonstrated atrial fibrillation.", + "The ECG demonstrated right bundle branch block.", + "The QRS interval was 132 ms.", + "Within 3 h of presentation, the QRS complexes reverted to narrow complexes.", + "He was in intermittent RBBB.", + "Remdesivir was started on Day 1 of hospitalization.", + "Remdesivir was given as a loading dose of 200 mg on Day 1.", + "Remdesivir was given as 100 mg daily for four additional days.", + "Dexamethasone 6 mg daily was started for 10 days.", + "Within 24 h of initiation of Remdesivir, he was noted to be in atrial fibrillation with slow ventricular rates between 30 and 40 b.p.m.", + "He was requiring 40 L/min of oxygen through a high flow nasal cannula.", + "He was transferred to the intensive care unit.", + "Two sets of troponins I were 0.028 and 0.022 ng/mL.", + "On Day 5 of Remdesivir therapy, he was noted to be persistently bradycardic.", + "ECG demonstrated atrial fibrillation with slow, fixed ventricular response, consistent with complete atrioventricular block.", + "Echocardiography showed an ejection fraction of 60%.", + "Echocardiography showed moderate pulmonary hypertension.", + "Echocardiography showed a dilated right ventricle.", + "Echocardiography showed mild aortic insufficiency.", + "Echocardiography showed moderate tricuspid insufficiency.", + "Echocardiography showed mildly reduced right ventricular function.", + "The AV block resolved spontaneously during the next 48 h.", + "ECG done on Day 10 demonstrated atrial fibrillation with ventricular rates between 52 and 58 b.p.m.", + "He was clinically improving.", + "His oxygen requirements decreased from 40 to 15 L/min.", + "He remained asymptomatic.", + "He had an adequate chronotropic response with activity.", + "Pacemaker implantation was not recommended.", + "Over the next 2 weeks, his oxygen requirements improved.", + "His heart rate remained between 48 and 60 b.p.m.", + "He was discharged home after a 3-week stay.", + "He was on 2 L/min of supplemental oxygen at discharge.", + "He died ∼2 weeks after being discharged from the hospital.", + "The cause of his death was not known." + ], + "summary": "A 72-year-old male with a history of atrial fibrillation and lung cancer was hospitalized for COVID-19. Electrocardiogram (ECG) on admission demonstrated atrial fibrillation and right bundle branch block. He was started on a course of Dexamethasone and Remdesivir. Within 24 h of starting Remdesivir, he was noted to be in atrial fibrillation with ventricular rates between 30 and 40 b.p.m. On Day 5 of Remdesivir therapy, ECG demonstrated complete AV block. Having completed the Remdesivir regimen, during the next 48 h, he was closely monitored, and the AV block resolved spontaneously. As he remained asymptomatic and had an adequate chronotropic response with activity, pacemaker implantation was not recommended.", + "summary_subclaims": [ + "The patient was a 72-year-old male.", + "The patient had a history of atrial fibrillation.", + "The patient had a history of lung cancer.", + "The patient was hospitalized for COVID-19.", + "Electrocardiogram on admission demonstrated atrial fibrillation.", + "Electrocardiogram on admission demonstrated right bundle branch block.", + "He was started on a course of Dexamethasone.", + "He was started on a course of Remdesivir.", + "Within 24 h of starting Remdesivir, he was noted to be in atrial fibrillation with ventricular rates between 30 and 40 b.p.m.", + "On Day 5 of Remdesivir therapy, ECG demonstrated complete AV block.", + "Having completed the Remdesivir regimen, during the next 48 h, he was closely monitored.", + "The AV block resolved spontaneously.", + "As he remained asymptomatic and had an adequate chronotropic response with activity, pacemaker implantation was not recommended." + ] + }, + { + "id": "multiclinsum_test_2021_en.txt", + "fulltext": "A 30-year-old pregnant Japanese woman was diagnosed with GDM at 23 weeks and 3 days of gestation during her first pregnancy, based on the results of a 75-g oral glucose tolerance test (OGTT). Her blood glucose levels before the test, after 60 min, and after 120 min were 81 mg/dL, 151 mg/dL, and 180 mg/dL, respectively. She was not obese before the pregnancy, had a height of 163 cm, a body weight of 54 kg, a body mass index (BMI) of 20.3 kg/m2 and had no family history of diabetes. She received dietary counselling, began SMBG (ONETOUCH UltraVue™ Johnson & Johnson, New Brunswick, NJ), and successfully achieved good glycemic control until the day of her delivery (a healthy boy with a birth weight of 3164 g). At 3 months after the delivery, she completed a follow-up 75-g OGTT, and the blood glucose levels before the test, after 30 min, after 60 min, and after 120 min were 82 mg/dL, 146 mg/dL, 102 mg/dL, and 189 mg/dL, respectively. Her plasma insulin levels before the test and after 30 min were 2.20 μU/mL and 33.2 μU/ml, respectively. Therefore, she was diagnosed with IGT based on these results, an insulinogenic index of 0.48, and a homeostatic model assessment of insulin resistance (HOMA-IR) result of 0.44. Thereafter, her HbA1c level was regularly monitored and ranged from 5.4% to 5.7%.\nAt the age of 33 years, the patient became pregnant with twins. At approximately 5 weeks of gestation, her SMBG began showing high postprandial glucose levels (up to 140–180 mg/dL), and she began self-administered insulin injections using insulin aspart (Novo Nordisk) three times per day before each meal. The doses of these insulin injections increased with gestational age, and reached 20–22 units before each meal. At 31 weeks and 3 days of gestation, the patient was urgently admitted to our hospital due to premature labor contractions. We initiated a continuous intravenous infusion (500 mL/day of 5% glucose solution containing 50 mg of ritodrine) that was continued until the day of her delivery. The patient experienced adverse effects from the ritodrine, required complete bed rest, and her glucose levels kept increasing (2200 kcal/day in 3 meals). Even with 25 units of injected insulin before each meal, her postprandial glucose levels increased to 211 mg/dL at 2 h after lunch, and she occasionally experienced hypoglycemia (59 mg/dL at 3 h after lunch or 50 mg/dL at approximately 10 PM). Thus, to reduce the fluctuations in her glucose levels, her food intake (2200 kcal/day with 59% carbohydrates, 15% protein, and 26% fat) was separated into 5 meals: first breakfast at 8 AM, second breakfast at 10 AM, first lunch at noon, second lunch at 3 PM, and dinner at 6 PM. The patient also received 1 cup of yoghurt immediately before going to sleep . However, the patient subsequently experienced abdominal distension and difficulty eating, and we reduced her intake to 1960 kcal/day .\nBased on the increased meal frequency, the patient required more frequent SMBG and insulin injections, which she found to be painful and depressing. Thus, we introduced the FGM system, which does not require finger punctures, to reduce her physical and emotional burden. During the first few days after its introduction, the FGM system exhibited discrepancies with the results from the conventional SMBG method, especially when her glucose levels were <70 mg/dL or >180 mg/dL. Therefore, she measured her glucose levels using both methods when her glucose levels were abnormally high or low. The patient also experienced difficulty consuming the second breakfast because of the short interval between the first and second breakfasts. Thus, her intake was revised to 1960 kcal/day (53% carbohydrates, 21% protein, and 26% fat) in 4 meals: breakfast at 8 AM, first lunch at noon, second lunch at 3 PM, and dinner at 6 PM. The re-distributed meals and flash glucose monitoring system allowed the patient to achieve good glycemic control, and the doses of the injected insulin decreased to 35 units and then to 18 units . Her HbA1c level was maintained, ranging from 5.1% to 5.2% (these values were considered as a reference due to her anemia), and her glycoalbumin levels ranged from 10.6% to 11.6% during pregnancy. She gained 10.5 kg during her pregnancy and subsequently delivered twins via Caesarean procedure (2280 g and 2778 g) at 37 weeks and 1 day of gestation, without any adverse events or hypoglycemia. After the delivery, the patient stopped all insulin injections and had glucose levels of 70–140 mg/dL throughout the day with a normal puerperium diet (2200 kcal/day in 3 meals) . The patient and her twins were discharged in healthy states at 7 days after the delivery.", + "fulltext_subclaims": [ + "The patient was a 30-year-old pregnant Japanese woman.", + "She was diagnosed with GDM at 23 weeks and 3 days of gestation during her first pregnancy.", + "The diagnosis was based on the results of a 75-g oral glucose tolerance test (OGTT).", + "Her blood glucose levels before the test, after 60 min, and after 120 min were 81 mg/dL, 151 mg/dL, and 180 mg/dL, respectively.", + "She was not obese before the pregnancy.", + "She had a height of 163 cm, a body weight of 54 kg, and a body mass index (BMI) of 20.3 kg/m2.", + "She had no family history of diabetes.", + "She received dietary counselling.", + "She began SMBG using ONETOUCH UltraVue™ Johnson & Johnson.", + "She successfully achieved good glycemic control until the day of her delivery.", + "She delivered a healthy boy with a birth weight of 3164 g.", + "At 3 months after the delivery, she completed a follow-up 75-g OGTT.", + "Her blood glucose levels before the test, after 30 min, after 60 min, and after 120 min were 82 mg/dL, 146 mg/dL, 102 mg/dL, and 189 mg/dL, respectively.", + "Her plasma insulin levels before the test and after 30 min were 2.20 μU/mL and 33.2 μU/mL, respectively.", + "She was diagnosed with IGT based on these results.", + "Her insulinogenic index was 0.48.", + "Her homeostatic model assessment of insulin resistance (HOMA-IR) result was 0.44.", + "Her HbA1c level ranged from 5.4% to 5.7%.", + "At the age of 33 years, the patient became pregnant with twins.", + "At approximately 5 weeks of gestation, her SMBG began showing high postprandial glucose levels (up to 140–180 mg/dL).", + "She began self-administered insulin injections using insulin aspart three times per day before each meal.", + "The doses of these insulin injections increased with gestational age and reached 20–22 units before each meal.", + "At 31 weeks and 3 days of gestation, the patient was urgently admitted to the hospital due to premature labor contractions.", + "A continuous intravenous infusion of 500 mL/day of 5% glucose solution containing 50 mg of ritodrine was initiated.", + "The infusion was continued until the day of her delivery.", + "The patient experienced adverse effects from the ritodrine.", + "She required complete bed rest.", + "Her glucose levels kept increasing (2200 kcal/day in 3 meals).", + "Even with 25 units of injected insulin before each meal, her postprandial glucose levels increased to 211 mg/dL at 2 h after lunch.", + "She occasionally experienced hypoglycemia (59 mg/dL at 3 h after lunch or 50 mg/dL at approximately 10 PM).", + "To reduce the fluctuations in her glucose levels, her food intake was separated into 5 meals.", + "The patient also received 1 cup of yoghurt immediately before going to sleep.", + "The patient subsequently experienced abdominal distension and difficulty eating.", + "Her intake was reduced to 1960 kcal/day.", + "The patient required more frequent SMBG and insulin injections, which she found to be painful and depressing.", + "We introduced the FGM system to reduce her physical and emotional burden.", + "During the first few days after its introduction, the FGM system exhibited discrepancies with the results from the conventional SMBG method.", + "The discrepancies were especially noted when her glucose levels were <70 mg/dL or >180 mg/dL.", + "She measured her glucose levels using both methods when her glucose levels were abnormally high or low.", + "The patient experienced difficulty consuming the second breakfast because of the short interval between the first and second breakfasts.", + "Her intake was revised to 1960 kcal/day in 4 meals.", + "The re-distributed meals and flash glucose monitoring system allowed the patient to achieve good glycemic control.", + "The doses of the injected insulin decreased to 35 units and then to 18 units.", + "Her HbA1c level was maintained, ranging from 5.1% to 5.2%.", + "Her glycoalbumin levels ranged from 10.6% to 11.6% during pregnancy.", + "She gained 10.5 kg during her pregnancy.", + "She delivered twins via Caesarean procedure at 37 weeks and 1 day of gestation.", + "The twins weighed 2280 g and 2778 g.", + "There were no adverse events or hypoglycemia.", + "After the delivery, the patient stopped all insulin injections.", + "She had glucose levels of 70–140 mg/dL throughout the day with a normal puerperium diet.", + "The patient and her twins were discharged in healthy states at 7 days after the delivery." + ], + "summary": "We report the case of a pregnant Japanese woman who experienced gestational diabetes mellitus during her first pregnancy and developed impaired glucose tolerance after the delivery. During her second pregnancy with twins, she required up to 75 units of injected insulin to control her postprandial hyperglycemia and occasionally experienced hypoglycemia. We used a newly developed flash glucose monitoring system, which allowed her to successfully achieve ideal glycemic control and experience an uncomplicated delivery.", + "summary_subclaims": [ + "The patient is a pregnant Japanese woman.", + "She experienced gestational diabetes mellitus during her first pregnancy.", + "She developed impaired glucose tolerance after the delivery.", + "During her second pregnancy with twins, she required up to 75 units of injected insulin to control her postprandial hyperglycemia.", + "She occasionally experienced hypoglycemia.", + "A newly developed flash glucose monitoring system was used.", + "The flash glucose monitoring system allowed her to successfully achieve ideal glycemic control.", + "She experienced an uncomplicated delivery." + ] + }, + { + "id": "multiclinsum_test_1419_en.txt", + "fulltext": "A 62-year-old male presented to an outpatient ophthalmologist with a 5-day history of progressive binocular diplopia and was referred to our institution. On presentation, neurologic and ophthalmologic examination showed a right pupil-involving partial third nerve palsy with no other abnormal findings. Routine brain magnetic resonance imaging (MRI) and time-of-flight MR angiography (MRA) demonstrated an AVM located in the right frontal operculum extending to the anterior insula with venous drainage into the right basal vein of Rosenthal. There was no subarachnoid or intraparenchymal hemorrhage to suggest AVM rupture. A diagnostic cerebral angiogram was performed next and demonstrated a 1.9 cm × 2.2 cm AVM fed by the right middle and accessory meningeal and sphenopalatine arteries and opercular branches of the middle cerebral artery (MCA). The venous drainage followed a deep pattern into a dilated and tortuous right basal vein of Rosenthal to the vein of Galen and ultimately into the straight sinus . The patient underwent staged embolizations of the feeding pedicles using Onyx-18 embolic material (Medtronic, Minneapolis, USA) to facilitate planned surgical resection. In the first stage, superselective catheterization of the right middle meningeal, accessory meningeal, and sphenopalatine arteries was performed using a Marathon microcatheter (Medtronic, Minneapolis, USA) and a Synchro 10 microwire (Stryker, Kalamazoo, USA) . In the second stage, the next day, the feeding branches of the opercular segment of the MCA were accessed with a Scepter balloon-guided microcatheter (MicroVention Inc., Tustin, USA) and a Synchro 2 microwire . On the following day, the patient underwent a right pterional craniotomy for resection of the AVM. An intraoperative control angiogram confirmed complete obliteration of the AVM [ and ]. The pathologic tissue examination was consistent with AVM.\nAt the 4-week follow-up, the patient reported complete resolution of the diplopia. Neurologic examination demonstrated no deficits and isocoric pupils with intact extraocular movements bilaterally. There was no recurrence of the diplopia 6 months after surgery.", + "fulltext_subclaims": [ + "A 62-year-old male presented with a 5-day history of progressive binocular diplopia.", + "The patient was referred to the institution.", + "On presentation, there was a right pupil-involving partial third nerve palsy.", + "Routine brain MRI and time-of-flight MRA demonstrated an AVM located in the right frontal operculum extending to the anterior insula.", + "The AVM drained into the right basal vein of Rosenthal.", + "There was no subarachnoid or intraparenchymal hemorrhage.", + "A diagnostic cerebral angiogram demonstrated a 1.9 cm × 2.2 cm AVM.", + "The AVM was fed by the right middle and accessory meningeal and sphenopalatine arteries and opercular branches of the MCA.", + "The venous drainage followed a deep pattern into a dilated and tortuous right basal vein of Rosenthal.", + "The patient underwent staged embolizations of the feeding pedicles using Onyx-18 embolic material.", + "In the first stage, superselective catheterization of the right middle meningeal, accessory meningeal, and sphenopalatine arteries was performed.", + "In the second stage, the feeding branches of the opercular segment of the MCA were accessed.", + "The patient underwent a right pterional craniotomy for resection of the AVM.", + "An intraoperative control angiogram confirmed complete obliteration of the AVM.", + "The pathologic tissue examination was consistent with AVM.", + "At the 4-week follow-up, the patient reported complete resolution of the diplopia.", + "Neurologic examination demonstrated no deficits.", + "There was no recurrence of the diplopia 6 months after surgery." + ], + "summary": "The authors report the case of a 62-year-old male who presented with diplopia for 5 days. Magnetic resonance imaging and angiography demonstrated a Spetzler-Martin Grade 2 AVM located in the right frontal operculum with deep drainage into the basal vein of Rosenthal causing ipsilateral oculomotor neuropathy. The patient underwent staged embolizations of the feeding pedicles, which were derived from the internal as well as external carotid circulation. This was followed by a right pterional craniotomy for resection of the AVM. The patient reported complete resolution of the diplopia over 4 weeks with no recurrence at the 6-month follow-up appointment.", + "summary_subclaims": [ + "The authors report the case of a 62-year-old male who presented with diplopia for 5 days.", + "Magnetic resonance imaging and angiography demonstrated a Spetzler-Martin Grade 2 AVM located in the right frontal operculum.", + "The AVM had deep drainage into the basal vein of Rosenthal.", + "The AVM caused ipsilateral oculomotor neuropathy.", + "The patient underwent staged embolizations of the feeding pedicles.", + "The feeding pedicles were derived from the internal as well as external carotid circulation.", + "The patient had a right pterional craniotomy for resection of the AVM.", + "The patient reported complete resolution of the diplopia over 4 weeks.", + "There was no recurrence at the 6-month follow-up appointment." + ] + }, + { + "id": "multiclinsum_test_2999_en.txt", + "fulltext": "A 9-year-old male child patient presented with history of fall from bicycle after which he was unable to bear weight on the left lower limb. He was treated elsewhere with splinting for 4 weeks. After removal of splint he was still unable to bear weight on the injured limb due to pain. At the time of presentation to us, the child has an antalgic gait. On clinical examination, he had deformity of flexion abduction and external rotation with painful restricted movements of hip suggestive of anterior dislocation of hip. Examination of opposite hip, spine and knees is normal. Radiological examination confirmed the diagnosis . There were no associated fractures and distal neurovascular status was intact. An open reduction of the joint through the anterior approach is planned and using the Somerville approach, the hip is approached . Acetabulum is exposed and cleared of pulvinar tissue. We passed 2.5 mm smooth k wire in to the femoral epiphysis though lateral cortex and neck to prevent separation of physis during reduction in to acetabulum. Lateral traction is applied with a bone hook under the neck of femur. Reduction is achieved with difficulty. Intra-operatively, reduction is checked under fluoroscopy and is found to be stable, congruent and concentric through all range of motions of hip . K-wire is removed and capsulorraphy is done. Post operatively, skin traction is applied for 2 weeks. Post-operative period is uneventful and X rays confirmed the intra-operative congruency . Rehabilitation protocol included partial weight bearing after 2 weeks till 4 weeks. After 6 weeks the child is allowed to squat and sit cross-legged. At final follow up of 1 year, the child is able to perform all activities of daily living without any difficulty [Image 4] and X-rays showed no signs of osteonecrosis of head or any joint space reduction [, ].", + "fulltext_subclaims": [ + "The patient is a 9-year-old male child.", + "He had a fall from a bicycle.", + "He was unable to bear weight on the left lower limb.", + "He was treated elsewhere with splinting for 4 weeks.", + "After removal of the splint, he was still unable to bear weight on the injured limb due to pain.", + "At the time of presentation, the child has an antalgic gait.", + "On clinical examination, he had deformity of flexion abduction and external rotation with painful restricted movements of the hip.", + "The deformity is suggestive of anterior dislocation of the hip.", + "Radiological examination confirmed the diagnosis.", + "There were no associated fractures.", + "Distal neurovascular status was intact.", + "An open reduction of the joint through the anterior approach is planned.", + "The hip is approached using the Somerville approach.", + "The acetabulum is exposed and cleared of pulvinar tissue.", + "A 2.5 mm smooth k wire is passed into the femoral epiphysis through the lateral cortex and neck.", + "Lateral traction is applied with a bone hook under the neck of the femur.", + "Reduction is achieved with difficulty.", + "Intra-operatively, reduction is checked under fluoroscopy.", + "The reduction is found to be stable, congruent, and concentric through all range of motions of the hip.", + "The k-wire is removed.", + "Capsulorraphy is done.", + "Post operatively, skin traction is applied for 2 weeks.", + "The post-operative period is uneventful.", + "X-rays confirmed the intra-operative congruency.", + "The rehabilitation protocol included partial weight bearing after 2 weeks till 4 weeks.", + "After 6 weeks, the child is allowed to squat and sit cross-legged.", + "At final follow up of 1 year, the child is able to perform all activities of daily living without any difficulty.", + "X-rays showed no signs of osteonecrosis of the head.", + "X-rays showed no signs of joint space reduction." + ], + "summary": "A 9-year-old male child presented with neglected anterior hip dislocation on left side. Open reduction carried out through direct anterior approach to hip. Congruent reduction is achieved. At final follow up of 1 year, the child had unrestricted activities of daily living and no radiological signs of osteonecrosis or any joint space reduction.", + "summary_subclaims": [ + "A 9-year-old male child presented with neglected anterior hip dislocation on left side.", + "Open reduction was carried out through direct anterior approach to hip.", + "Congruent reduction is achieved.", + "At final follow up of 1 year, the child had unrestricted activities of daily living.", + "There were no radiological signs of osteonecrosis.", + "There was no joint space reduction." + ] + }, + { + "id": "multiclinsum_test_3137_en.txt", + "fulltext": "A 68-year-old female first admitted to our hospital because of heart failure, and was finally diagnosed as an AL type of primary cardiac amyloidosis including the endomyocardial biopsy. After 3 years followed-up, she underwent a CRT device implantation for biventricular pacing following the repeated episodes of heart failure (NYHA class III) with reduced left ventricular ejection fraction of 34% and wide QRS with complete left bundle branch block of 143 ms. She kept a silent condition for 7 years after a CRT device implantation. A shortness of breath, symptoms of heart failure on physical examination, and remarkable cardiomegaly with extended cardiothoracic ratio of 74% on chest x-ray were again presented when she was 78 years old. The echocardiography showed a huge echogenic mass occupying the right atrium. Sixty-four multi-detector computed tomography (CT) showed a lobulated heterogeneously enhancing mass in the right upper lobe of liver, and a continuous tumor thrombus from the portal vein and hepatic vein to the right atrium via the inferior vena cava. Alpha-fetoprotein level was >20 000 ng/mL (reference range: 0.0 to 10.0 ng/mL), and HCC was diagnosed by a contrast enhanced CT. The continuous hypercoagulability was shown more than 6 months before the last occurrence of heart failure despite of anticoagulant therapy. She improved the symptoms of heart failure by the diuretics as a standard medical therapy. An extensive tumor thrombus with HCC was considered to have caused a hemodynamic complication in this case.", + "fulltext_subclaims": [ + "The patient is a 68-year-old female.", + "She was admitted to the hospital because of heart failure.", + "She was diagnosed with AL type of primary cardiac amyloidosis.", + "The diagnosis was confirmed by endomyocardial biopsy.", + "After 3 years of follow-up, she underwent CRT device implantation.", + "The CRT device was implanted for biventricular pacing.", + "She had repeated episodes of heart failure with NYHA class III.", + "Her left ventricular ejection fraction was 34%.", + "She had a wide QRS with complete left bundle branch block of 143 ms.", + "She remained asymptomatic for 7 years after CRT device implantation.", + "At age 78, she presented with shortness of breath.", + "She had symptoms of heart failure on physical examination.", + "Chest x-ray showed a cardiothoracic ratio of 74%.", + "Echocardiography showed a huge echogenic mass in the right atrium.", + "CT showed a lobulated heterogeneously enhancing mass in the right upper lobe of the liver.", + "A continuous tumor thrombus was present from the portal vein and hepatic vein to the right atrium via the inferior vena cava.", + "Alpha-fetoprotein level was >20 000 ng/mL.", + "HCC was diagnosed by contrast-enhanced CT.", + "Continuous hypercoagulability was present more than 6 months before the last heart failure episode.", + "She received anticoagulant therapy.", + "She improved symptoms of heart failure with diuretics.", + "An extensive tumor thrombus with HCC was considered to have caused a hemodynamic complication." + ], + "summary": "Patient: Female, 68\n\nFinal Diagnosis: Hepatocellular carcinoma\n\nSymptoms: Shortness of breath\n\nMedication: —\n\nClinical Procedure: Cardiac resynchronization therapy\n\nSpecialty: Cardiology\n\nA 68-year-old female first admitted to our hospital because of heart failure with an AL type primary cardiac amyloidosis. After 3 years, she underwent an implantation of a CRT device for biventricular pacing following repeated episodes of heart failure and low left ventricular ejection fraction of 34% with NYHA class III. Again, she presented with symptoms of heart failure and cardiomegaly on chest x-ray at 7 years after the CRT device implantation. The echocardiography showed a huge echogenic mass occupying the right atrium, and 64 multi-detector computed tomography showed a lobulated heterogeneously enhancing mass of hepatocellular carcinoma in the right upper lobe of her liver and a continuous tumor thrombus from the portal vein and hepatic vein to the right atrium via the inferior vena cava.", + "summary_subclaims": [ + "The patient is a 68-year-old female.", + "The final diagnosis is hepatocellular carcinoma.", + "The patient had symptoms of shortness of breath.", + "The patient did not have any medication listed.", + "The clinical procedure was cardiac resynchronization therapy.", + "The specialty was cardiology.", + "The patient was first admitted because of heart failure with an AL type primary cardiac amyloidosis.", + "The patient underwent implantation of a CRT device for biventricular pacing.", + "The CRT device implantation occurred after repeated episodes of heart failure.", + "The left ventricular ejection fraction was 34%.", + "The patient had NYHA class III heart failure.", + "The patient presented with symptoms of heart failure at 7 years after CRT device implantation.", + "The chest x-ray showed cardiomegaly.", + "Echocardiography showed a huge echogenic mass occupying the right atrium.", + "64 multi-detector computed tomography showed a lobulated heterogeneously enhancing mass of hepatocellular carcinoma in the right upper lobe of her liver.", + "The tumor thrombus extended from the portal vein and hepatic vein to the right atrium via the inferior vena cava." + ] + }, + { + "id": "multiclinsum_test_3368_en.txt", + "fulltext": "9-year-old schoolchild, second child of non-blood parents, height 167 cm father and 160 cm mother (average for Chilean population), she has a history of pulmonary sarcoidosis. Her 11-year-old older sister had an advanced bone age of 13 years at 10 years and 7 months of chronological age, without associated height alteration. She was also diagnosed with attention deficit hyperactivity disorder (ADHD) and overweight, without associated cognitive alterations or dysmorphies.\n\nThe pregnancy was monitored, without associated pathologies and she was born at 37 weeks of gestational age by caesarean section with a weight of 3,960 kg (2.25 SD) classified as large for gestational age, height of 51 cm (1.04 SD), CC of 37.5 cm (3.62 SD) according to the curves of Alarcón and Pittaluga, and APGAR score 9-9.\n\nDuring his neonatal stage he presented hypotonic syndrome managed with motor rehabilitation with good evolution. As for his psychomotor development, he walked at 15 months of age and presented a delay in the start of language. At 7 years old he was diagnosed with verbal and motor dyspraxia, and at 9 years old he was in the process of acquiring reading and writing skills in a special school.\n\nShe was above the normal growth curves for height, weight and WHR from infancy. At 9 years old, she had a weight of 57.7 kg (2.67 SD), height 150 cm (2.42 SD), body mass index (BMI) 25.6 (2.48 SD) according to WHO anthropometric curves, WHR 57.5 (≥ 2 SD) according to Nellhaus curves, and a wingspan of 160 cm, with proportionate body segments. Her pubertal development at 9 years old was Tanner I, consistent with her age. She did not have any eating disorders throughout her life.\n\nHis hormonal and biochemical tests including thyroid hormones, IGF-1, gonadotrophins, testosterone, calcium-phosphorus, glycemia and glycosylated hemoglobin were within normal ranges. He presented an altered lipid profile at 9 years of age with a total cholesterol of 196 mg/dL and triglycerides of 162 mg/ dL. His wrist x-ray showed an advanced bone age of 13 years at his chronological age of 8 years and 10 months.\n\nIn the neurological sphere, he was diagnosed with mild DI, high-functioning autism spectrum disorder (ASD) and ADHD, and was being treated with methylphenidate 10 mg daily. His main neurocognitive manifestations were difficulties in expressive language with dyslalia, alterations in fine motor skills and sensory modulation. He had difficulties in maintaining sleep. Throughout his life, he received comprehensive treatment with speech therapy, occupational therapy and psychopedagogy, showing positive progress in all areas with the therapies and without diagnoses of behavioural or conduct disorders. He had an altered electroencephalogram with very frequent left temporal interictal epileptiform activity, with no history of convulsions, and a brain MRI was performed at the age of 9 with normal results.\n\nCardiovascular evaluation showed no cardiac anomalies, normal blood pressure, normal electrocardiogram, normal Holter rhythm and normal echocardiographic evaluation.\n\nOther studies included mild neutropenia (absolute neutrophil count of 1,470/uL), with study of the V617F variant in the JAK-2 gene for negative myeloproliferative syndrome. Audiometry and impedanciometry without alterations, and normal abdominal echotomy. He was operated on for adenoidectomy at 3 years and 6 months.\n\nFrom the genetic point of view, he was studied by karyogram with a 46,XY karyotype and the diagnosis of Fragile X Syndrome was ruled out by molecular study with triple PCR (TP-PCR) due to his language delay.\n\nAt 9 years of age, he was evaluated by a clinical geneticist and was found to have coarse features, light hair, prominent forehead, narrow temple, prominent and horizontal eyebrows, low-set auricles, enlarged orbital rim, broad and flat nasal bridge, long eyelashes, descending palpebral fissures, deep-set green eyes, bilateral infraorbital crease, full cheeks, anteverted nostrils, cupid shaped upper lip and full lower lip, and prominent upper central incisors. Apart from the facial dysmorphies described, no other dysmorphic features were found on a full physical examination of the patient.\n\nIt was studied by WES in the commercial laboratory CENTOGENE through an Illumina platform, and a heterozygous variant in the DNMT3A gene, NM_022552.4:c.2311C > T, p. (Arg771*), located on chromosome 2 at position 25463182 (Reference position rs779626155) according to the GRCh37/hg19 version of the human genome was detected. The detected variant is in a region of adequate coverage and depth by the sequencing reads (> 20x) and was confirmed by Sanger sequencing. The variant generates a premature stop codon and according to the criteria of the American College of Medical Genetics and Genomics (ACMG) was classified as probably pathogenic. This variant has not been previously identified in individuals with STBR, however, it has been described associated with colorectal adenocarcinoma.\n\nGiven the sister's history of advanced bone age, overweight and TADH, she was also studied by WES, ruling out the presence of the DNMT3A variant identified in the proband, and no pathogenic variants associated with the described phenotype were identified. The parents of the identified variant could not be studied for segregation, however, neither of them presented alterations in the clinical history or dysmorphies at the physical examination suggestive of disease, both having a history of normal intellectual, anthropometric and pubertal development.\n", + "fulltext_subclaims": [ + "The patient is a 9-year-old schoolchild.", + "The patient's father is 167 cm tall.", + "The patient's mother is 160 cm tall.", + "The patient has a history of pulmonary sarcoidosis.", + "The patient's 11-year-old older sister had an advanced bone age of 13 years at 10 years and 7 months of chronological age.", + "The patient's older sister did not have associated height alteration.", + "The patient's older sister was diagnosed with attention deficit hyperactivity disorder.", + "The patient's older sister was overweight.", + "The patient's older sister did not have associated cognitive alterations.", + "The patient's older sister did not have dysmorphies.", + "The pregnancy was monitored without associated pathologies.", + "The patient was born at 37 weeks of gestational age.", + "The patient was born by caesarean section.", + "The patient's birth weight was 3,960 kg.", + "The patient's birth weight was classified as large for gestational age.", + "The patient's birth weight had a 2.25 SD.", + "The patient's birth height was 51 cm.", + "The patient's birth head circumference was 37.5 cm.", + "The patient's APGAR score was 9-9.", + "During the neonatal stage, the patient presented hypotonic syndrome.", + "The patient's hypotonic syndrome was managed with motor rehabilitation.", + "The patient's motor rehabilitation had good evolution.", + "The patient walked at 15 months of age.", + "The patient presented a delay in the start of language.", + "At 7 years old, the patient was diagnosed with verbal and motor dyspraxia.", + "At 9 years old, the patient was in the process of acquiring reading and writing skills in a special school.", + "The patient was above the normal growth curves for height, weight and WHR from infancy.", + "At 9 years old, the patient had a weight of 57.7 kg.", + "At 9 years old, the patient had a height of 150 cm.", + "At 9 years old, the patient had a body mass index of 25.6.", + "At 9 years old, the patient had a waist-to-height ratio of 57.5.", + "The patient's pubertal development at 9 years old was Tanner I.", + "The patient's pubertal development was consistent with her age.", + "The patient did not have any eating disorders throughout her life.", + "The patient's thyroid hormones were within normal ranges.", + "The patient's IGF-1 was within normal ranges.", + "The patient's gonadotrophins were within normal ranges.", + "The patient's testosterone was within normal ranges.", + "The patient's calcium-phosphorus was within normal ranges.", + "The patient's glycemia was within normal ranges.", + "The patient's glycosylated hemoglobin was within normal ranges.", + "The patient had an altered lipid profile at 9 years of age.", + "The patient's total cholesterol was 196 mg/dL.", + "The patient's triglycerides were 162 mg/dL.", + "The patient's wrist x-ray showed an advanced bone age of 13 years.", + "The patient's chronological age at the time of the wrist x-ray was 8 years and 10 months.", + "The patient was diagnosed with mild developmental delay.", + "The patient was diagnosed with high-functioning autism spectrum disorder.", + "The patient was diagnosed with attention deficit hyperactivity disorder.", + "The patient was being treated with methylphenidate 10 mg daily.", + "The patient had difficulties in expressive language with dyslalia.", + "The patient had alterations in fine motor skills.", + "The patient had difficulties in maintaining sleep.", + "The patient received comprehensive treatment with speech therapy.", + "The patient received comprehensive treatment with occupational therapy.", + "The patient received comprehensive treatment with psychopedagogy.", + "The patient showed positive progress in all areas with the therapies.", + "The patient did not have diagnoses of behavioural or conduct disorders.", + "The patient had an altered electroencephalogram with very frequent left temporal interictal epileptiform activity.", + "The patient had no history of convulsions.", + "The patient had a normal brain MRI at the age of 9.", + "The patient's cardiovascular evaluation showed no cardiac anomalies.", + "The patient's blood pressure was normal.", + "The patient's electrocardiogram was normal.", + "The patient's Holter rhythm was normal.", + "The patient's echocardiographic evaluation was normal.", + "The patient had mild neutropenia with an absolute neutrophil count of 1,470/uL.", + "The patient's V617F variant in the JAK-2 gene was negative.", + "The patient's audiometry and impedanciometry were without alterations.", + "The patient's abdominal echotomy was normal.", + "The patient was operated on for adenoidectomy at 3 years and 6 months.", + "The patient had a 46,XY karyotype.", + "The patient's Fragile X Syndrome was ruled out by molecular study with triple PCR.", + "The patient was evaluated by a clinical geneticist at 9 years of age.", + "The patient was found to have coarse features.", + "The patient had light hair.", + "The patient had a prominent forehead.", + "The patient had narrow temples.", + "The patient had prominent and horizontal eyebrows.", + "The patient had low-set auricles.", + "The patient had an enlarged orbital rim.", + "The patient had a broad and flat nasal bridge.", + "The patient had long eyelashes.", + "The patient had descending palpebral fissures.", + "The patient had deep-set green eyes.", + "The patient had a bilateral infraorbital crease.", + "The patient had full cheeks.", + "The patient had anteverted nostrils.", + "The patient had a cupid shaped upper lip.", + "The patient had a full lower lip.", + "The patient had prominent upper central incisors.", + "The patient did not have other dysmorphic features on a full physical examination.", + "The patient was studied by whole exome sequencing in the commercial laboratory CENTOGENE.", + "The patient had a heterozygous variant in the DNMT3A gene, NM_022552.4:c.2311C > T, p. (Arg771*).", + "The variant was located on chromosome 2 at position 25463182.", + "The variant was detected according to the GRCh37/hg19 version of the human genome.", + "The variant was in a region of adequate coverage and depth by the sequencing reads (> 20x).", + "The variant was confirmed by Sanger sequencing.", + "The variant generates a premature stop codon.", + "The variant was classified as probably pathogenic according to the criteria of the American College of Medical Genetics and Genomics.", + "The variant has not been previously identified in individuals with STBR.", + "The variant has been described associated with colorectal adenocarcinoma.", + "The patient's sister was studied by whole exome sequencing.", + "The patient's sister did not have the DNMT3A variant identified in the proband.", + "The patient's sister did not have pathogenic variants associated with the described phenotype.", + "The patient's parents could not be studied for segregation.", + "The patient's parents did not present alterations in the clinical history.", + "The patient's parents did not have dysmorphies at the physical examination.", + "The patient's parents had a history of normal intellectual development.", + "The patient's parents had a history of normal anthropometric development.", + "The patient's parents had a history of normal pubertal development." + ], + "summary": "9-year-old schoolboy diagnosed with STBR via whole exome sequencing (WES) who was identified with the DNMT3A variant: c.2311C > T, p. (Arg771*) not previously reported in the literature in individuals with the condition. He presented the main features of this syndrome with overgrowth from neonatal stage, mild intellectual disability associated with autism spectrum disorder, absence of major anomalies in internal organs and characteristic dysmorphies with coarse face, horizontal eyebrows and prominent upper central incisors. He had an altered electroencephalogram with frequent left temporal interictal epileptiform activity, without a history of convulsions, and a normal brain MRI. In addition, he had advanced bone age, a finding common in other overgrowth syndromes but not frequently reported in STBR. His sister's genetic study was normal and segregation study of the identified variant in the parents could not be performed.\n", + "summary_subclaims": [ + "The patient is a 9-year-old schoolboy.", + "The patient was diagnosed with STBR via whole exome sequencing.", + "The patient was identified with the DNMT3A variant: c.2311C > T, p. (Arg771*).", + "The DNMT3A variant was not previously reported in the literature in individuals with the condition.", + "The patient presented with overgrowth from the neonatal stage.", + "The patient had mild intellectual disability.", + "The patient had autism spectrum disorder.", + "The patient had no major anomalies in internal organs.", + "The patient had characteristic dysmorphies with a coarse face.", + "The patient had horizontal eyebrows.", + "The patient had prominent upper central incisors.", + "The patient had an altered electroencephalogram with frequent left temporal interictal epileptiform activity.", + "The patient had no history of convulsions.", + "The patient had a normal brain MRI.", + "The patient had advanced bone age.", + "Advanced bone age is common in other overgrowth syndromes.", + "Advanced bone age is not frequently reported in STBR.", + "The patient's sister's genetic study was normal.", + "Segregation study of the identified variant in the parents could not be performed." + ] + }, + { + "id": "multiclinsum_test_2138_en.txt", + "fulltext": "A 69-year-old female referred to the clinic with a painful lump in her left breast 3 months ago. She also complained of bloody discharge from left nipple four years ago.\nDespite recommendations for diagnostic procedure, the patient decided not to follow-up. On physical examination, an erythematous tender mass, owning hard consistency on palpation was detected around the nipple led to further radiological investigations. Sonography showed lobulated hypoecho mass with microcyctic areas measuring 20×17 mm at 3o’clock beside areol . Mammography also showed a hyperdense mass in retroareolar site. The patient was admitted and underwent surgery. According to the intraoperative pathology consultation based on multiple frozen sections from the mass, left modified radical mastectomy and lymph node dissection done.\nThe specimen was received in formalin. On serial sectioning, there were tan-brown firm mass with multiple cystic areas. On gross examination, the surgical margins are free from tumoral cells and nipple was retracted . Sections were taken and stained by hematoxylin and eosin. Microscopically, neoplastic tissue was seen, composed of dilated ducts, filling by papillary projections, cribriform and fused glands, lined by mild to moderate atypical cells with scattered mitoses and without distinct, myoepithelial layer mostly floating in mucinous lakes with invasion to surrounding stroma . Foci of ductal carcinoma in situ including cribriform, papillary and micropapillary pattern were present in about 30% of tumor bulk. All surgical margins were free of tumor. Insitu component with papillary feature was seen in nipple. Nearby skin-deep dermis was involved by tumor. All of 16 lymph nodes showed reactive changes. There was no perineural or lymphovascular invasion. Immunohistochemistry profile showed positive estrogen and progesterone receptors and negative for HER2 . The patient was finally discharged with regular follow-up.", + "fulltext_subclaims": [ + "The patient is a 69-year-old female.", + "She had a painful lump in her left breast 3 months ago.", + "She had bloody discharge from the left nipple four years ago.", + "The patient decided not to follow-up despite recommendations for diagnostic procedure.", + "On physical examination, an erythematous tender mass with hard consistency was detected around the nipple.", + "Sonography showed a lobulated hypoechoic mass with microcystic areas measuring 20×17 mm at 3 o'clock beside the areola.", + "Mammography showed a hyperdense mass in the retroareolar site.", + "The patient was admitted and underwent surgery.", + "Intraoperative pathology consultation based on multiple frozen sections from the mass was performed.", + "A left modified radical mastectomy and lymph node dissection were done.", + "The specimen was received in formalin.", + "On serial sectioning, there were tan-brown firm masses with multiple cystic areas.", + "The surgical margins were free from tumoral cells.", + "The nipple was retracted.", + "Sections were taken and stained by hematoxylin and eosin.", + "Microscopically, neoplastic tissue composed of dilated ducts filled by papillary projections, cribriform and fused glands was seen.", + "The neoplastic tissue was lined by mild to moderate atypical cells with scattered mitoses.", + "There was no distinct myoepathelial layer.", + "The neoplastic tissue was mostly floating in mucinous lakes with invasion to surrounding stroma.", + "Foci of ductal carcinoma in situ including cribriform, papillary, and micropapillary patterns were present in about 30% of the tumor bulk.", + "All surgical margins were free of tumor.", + "An in situ component with papillary features was seen in the nipple.", + "Nearby skin-deep dermis was involved by tumor.", + "All 16 lymph nodes showed reactive changes.", + "There was no perineural invasion.", + "There was no lymphovascular invasion.", + "Immunohistochemistry profile showed positive estrogen and progesterone receptors.", + "Immunohistochemistry profile showed negative for HER2.", + "The patient was discharged with regular follow-up." + ], + "summary": "In this article, we describe a case of a-69-year-old female with a painful mass in her left breast. Based on intraoperative pathology consult, neoplastic tissue mostly floating in mucinous lakes with invasion to surrounding stroma was seen. Immunohistochemistry profile showed positive estrogen and progesterone receptors and negative for HER2.", + "summary_subclaims": [ + "The patient is a 69-year-old female.", + "The patient had a painful mass in her left breast.", + "Intraoperative pathology consult showed neoplastic tissue mostly floating in mucinous lakes.", + "Invasion to surrounding stroma was seen.", + "Immunohistochemistry profile showed positive estrogen receptors.", + "Immunohistochemistry profile showed positive progesterone receptors.", + "Immunohistochemistry profile showed negative for HER2." + ] + }, + { + "id": "multiclinsum_test_1370_en.txt", + "fulltext": "A 53-year-old male was admitted to the outpatient department of the Second Hospital of Jilin University in February 2020, with swelling and pain on his left hip and proximal thigh, which he stated as having been developing over 5 days and aggravated with fever for 1 day. There was no history of trauma, and the patient was febrile (37.8 ℃). On physical examination, extensive redness and swelling spreading from the patient’s left buttocks to the thigh root could be seen at the lithotomy position, with high skin temperature and obvious tenderness; perianal connective tissue was detected protruding from the anus, and extensive soft tissue bulges were palpable on digital rectal examination, with obvious tenderness and a sense of fluctuation at the 6 o’clock position.\nUltrasound of the left buttocks showed the echo of abnormal soft tissue with a thickened subcutaneous layer and multiple low to anechoic stripe and flaky zones, where the most extensive area was 1.9 cm × 1.1 cm . A CT scan was obtained to further define the extent and nature of the lesion, confirming multiple patchy liquid and gas density shadows in the bilateral rectal sphincter space, bilateral ischiorectal space, left hip and left thigh root muscle space, with gas–liquid planes detected in the left hip, and the rectum wall was discontinuous at 6 o'clock . Blood examination revealed that the white blood cell count reached 16.4 × 10^9/L, with 15.7 × 10^9/L and 92.2% for neutrophils.\nThe patient was then diagnosed as gas-producing perianal abscess and admitted to the surgical ward with preparation for open surgery. The patient’s blood was collected for blood culture examination (5 ml cultivated for 5 days in BacT/ALERT FA culture bottles and BacT/ALERT FN culture bottles for aerobic and anaerobic bacteria detection, respectively, using BacT/ALERT 3D Microbial Detection Systems (BioMerieux Ltd., France)), and then the patient was managed with intravenous fluids and broad-spectrum antibiotics (ceftizoxime (2.0 g i.v. q12h), ornidazole (0.5 g i.v. q24h)) for empirical antibiotic therapy. On the second day after admission, the patient underwent extensive surgical debridement of the perianal abscess, revealing multiple pockets of necrotic tissue. The left hip and the proximal thigh were also debrided at multiple points where the undulations were noticeable, and then necrotic tissue was excised with drains put in place following the standard principles. Over 30 ml of slightly turbid pus was released, and one intraoperative tissue specimen was sent for bacterial culture.\nAlthough the perianal redness and swelling subsided obviously 2 days after the procedure, the patient was still febrile (38.3℃) with his left upper thigh continuing to be red and swollen, aggravated by tenderness and crepitus. CT of the left thigh showed extensive swollen soft tissue and massive gas density visible in the muscle space extending to the knee . An MRI was obtained to further confirm that soft tissue damage and gas and fluid signals could be detected between the subcutaneous tissue and muscle spaces through the left upper thigh . Blood was collected again for a culture test.\nConsidering insufficient debridement and the risk of incorrect identification of pathogens, the Division of Gastrointestinal Surgery and Orthopedics performed debridement of the left upper thigh together on the 4th day after the primary operation. A large amount of inflammatory and necrotic fascia and muscle tissue was excised.VSD (Vacuum Sealing Drainage) equipment was used for closing the wound and constant drainage. Anti-infection and supportive treatment were continued after the operation, combined with 800,000 UI gentamycin in 3000 ml of 0.9% NaCl for constant irrigation. The debridement tissue was sent for bacterial culture again and a 16S rDNA sequencing test.\nWhile the blood culture tests continued to be negative, the first sample taken intraoperatively was positive in the bacterial culture test, and later identified as coinfection of Escherichia coli and Enterococcus faecium by conventional phenotype methods using the COMPACT VITEK2 identification system (BioMerieux Ltd., France) 1 day after the second debridement . Drug sensitivity tests determined that the isolated Escherichia coli was sensitive to amikacin, ampicillin, ampicillin-Sulbactam, aztreonam, cefazolin, cefepime, cefotetan, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, imipenem, levofloxacin, meropenem, piperacillin, tobramycin, and trimethoprim, while the isolated Enterococcus faecium was sensitive to ampicillin, ciprofloxacin, erythromycin, high-level gentamicin, levofloxacin, linezolid, penicillin-G, tetracycline, tigecycline, and vancomycin. Although the specimen from the second surgery was negative in the bacterial culture test, the bacterial 16S rDNA from the patient sample was detected by PCR amplification with the 16S rDNA Bacterial Identification PCR Kit (Code No. RR176, TaKaRa, China). The sequence of the forward primer was 5′-GAGCGGATAACAATTTCACACAGG-3′, and the sequence of the reverse primer was 5′-CGCCAGGGTTTTCCCAGTCACGAC-3′. PCR results showed that there was an apparent PCR product of approximately 1600 bp representing the full-length 16S rDNA found in agarose gel . To clarify the classification of bacteria, DNA sequencing of this PCR amplicon was performed by the Sanger sequencing method . The chromatogram of 16S rDNA sequencing with different sequencing primers showed a single peak, indicating that one bacterial 16S rDNA fragment was present among PCR products . The bacteria were identified by searching and comparing the 16S rDNA sequences (see Additional file ) using the Silva database , which indicated that the bacteria have a 99% identity classification for Clostridium perfringens , and the phylogenetic tree was established by using the Basic Local Alignment Search Tool (BLAST) offered by the National Centre for Biotechnology Information (NCBI) database and confirmed that the isolate was most closely related to Clostridium perfringens .\nDue to the detection of Clostridium perfringens by 16S rDNA sequencing, the antibiotic regimen was then adjusted according to the results of drug sensitivity tests following bacterial cultures and DNA sequencing tests: meropenem (1 g i.v. q8h) and vancomycin (1 g i.v. q12h). The pain, redness, and swelling of the perianal area and left upper thigh continued to be relieved by this regimen. MRI indicated that although the soft tissue of the left thigh was obviously thickened, no obvious abnormal signal between/in the muscle and bone tissue was detected . Twelve days after the second debridement, another operation was performed again to remove the VSD equipment and close the wound. The blood examination taken on the 3rd and 5th days postoperatively showed no inflammation and the anti-infective treatment was then stopped. After another 3 days of close observation, the patient was discharged at 27 days of admission, and recovered well without adverse complaints at the time of 1-month follow-up.", + "fulltext_subclaims": [ + "The patient was a 53-year-old male.", + "He was admitted to the outpatient department of the Second Hospital of Jilin University in February 2020.", + "He had swelling and pain on his left hip and proximal thigh.", + "The symptoms had been developing over 5 days.", + "The symptoms were aggravated with fever for 1 day.", + "There was no history of trauma.", + "The patient was febrile at 37.8 ℃.", + "On physical examination, extensive redness and swelling spreading from the left buttocks to the thigh root was seen.", + "The skin temperature was high.", + "There was obvious tenderness.", + "Perianal connective tissue was detected protruding from the anus.", + "Extensive soft tissue bulges were palpable on digital rectal examination.", + "There was a sense of fluctuation at the 6 o’clock position.", + "Ultrasound showed the echo of abnormal soft tissue.", + "The subcutaneous layer was thickened.", + "Multiple low to anechoic stripe and flaky zones were present.", + "The most extensive area was 1.9 cm × 1.1 cm.", + "A CT scan was obtained.", + "Multiple patchy liquid and gas density shadows were detected in the bilateral rectal sphincter space.", + "Multiple patchy liquid and gas density shadows were detected in the bilateral ischiorectal space.", + "Multiple patchy liquid and gas density shadows were detected in the left hip.", + "Multiple patchy liquid and gas density shadows were detected in the left thigh root muscle space.", + "Gas–liquid planes were detected in the left hip.", + "The rectum wall was discontinuous at 6 o'clock.", + "The white blood cell count was 16.4 × 10^9/L.", + "The neutrophil count was 15.7 × 10^9/L.", + "The neutrophil percentage was 92.2%.", + "The patient was diagnosed as gas-producing perianal abscess.", + "He was admitted to the surgical ward.", + "Blood was collected for blood culture examination.", + "5 ml was cultivated for 5 days in BacT/ALERT FA culture bottles.", + "5 ml was cultivated for 5 days in BacT/ALERT FN culture bottles.", + "The patient was managed with intravenous fluids.", + "Empirical antibiotic therapy was started.", + "Ceftizoxime was administered at 2.0 g i.v. q12h.", + "Ornidazole was administered at 0.5 g i.v. q24h.", + "On the second day after admission, the patient underwent extensive surgical debridement of the perianal abscess.", + "Multiple pockets of necrotic tissue were revealed.", + "The left hip and proximal thigh were debrided at multiple points.", + "Necrotic tissue was excised.", + "Drains were put in place.", + "Over 30 ml of slightly turbid pus was released.", + "One intraoperative tissue specimen was sent for bacterial culture.", + "The perianal redness and swelling subsided obviously 2 days after the procedure.", + "The patient was still febrile at 38.3℃.", + "The left upper thigh continued to be red and swollen.", + "Tenderness and crepitus were aggravated.", + "CT of the left thigh showed extensive swollen soft tissue.", + "Massive gas density was visible in the muscle space extending to the knee.", + "An MRI was obtained.", + "Soft tissue damage and gas and fluid signals were detected between the subcutaneous tissue and muscle spaces.", + "Blood was collected again for a culture test.", + "The Division of Gastrointestinal Surgery and Orthopedics performed debridement of the left upper thigh on the 4th day after the primary operation.", + "A large amount of inflammatory and necrotic fascia and muscle tissue was excised.", + "VSD equipment was used for closing the wound.", + "Anti-infection and supportive treatment were continued.", + "800,000 UI gentamycin in 3000 ml of 0.9% NaCl was used for constant irrigation.", + "The debridement tissue was sent for bacterial culture again.", + "A 16S rDNA sequencing test was performed.", + "The first sample taken intraoperatively was positive in the bacterial culture test.", + "The bacteria were identified as coinfection of Escherichia coli and Enterococcus faecium.", + "The identification was done using the COMPACT VITEK2 system.", + "The identification was done 1 day after the second debridement.", + "The Escherichia coli was sensitive to amikacin.", + "The Escherichia coli was sensitive to ampicillin.", + "The Escherichia coli was sensitive to ampicillin-Sulbactam.", + "The Escherichia coli was sensitive to aztreonam.", + "The Escherichia coli was sensitive to cefazolin.", + "The Escherichia coli was sensitive to cefepime.", + "The Escherichia coli was sensitive to cefotetan.", + "The Escherichia coli was sensitive to ceftazidime.", + "The Escherichia coli was sensitive to ceftriaxone.", + "The Escherichia coli was sensitive to cefuroxime.", + "The Escherichia coli was sensitive to ciprofloxacin.", + "The Escherichia coli was sensitive to gentamicin.", + "The Escherichia coli was sensitive to imipenem.", + "The Escherichia coli was sensitive to levofloxacin.", + "The Escherichia coli was sensitive to meropenem.", + "The Escherichia coli was sensitive to piperacillin.", + "The Escherichia coli was sensitive to tobramycin.", + "The Escherichia coli was sensitive to trimethoprim.", + "The Enterococcus faecium was sensitive to ampicillin.", + "The Enterococcus faecium was sensitive to ciprofloxacin.", + "The Enterococcus faecium was sensitive to erythromycin.", + "The Enterococcus faecium was sensitive to high-level gentamicin.", + "The Enterococcus faecium was sensitive to levofloxacin.", + "The Enterococcus faecium was sensitive to linezolid.", + "The Enterococcus faecium was sensitive to penicillin-G.", + "The Enterococcus faecium was sensitive to tetracycline.", + "The Enterococcus faecium was sensitive to tigecycline.", + "The Enterococcus faecium was sensitive to vancomycin.", + "The specimen from the second surgery was negative in the bacterial culture test.", + "The bacterial 16S rDNA was detected by PCR amplification.", + "The PCR was done using the 16S rDNA Bacterial Identification PCR Kit.", + "The PCR product was approximately 1600 bp.", + "DNA sequencing of the PCR amplicon was performed by the Sanger sequencing method.", + "The chromatogram showed a single peak.", + "The 16S rDNA sequences were compared using the Silva database.", + "The bacteria were identified as Clostridium perfringens with 99% identity.", + "The phylogenetic tree was established using BLAST from NCBI.", + "The antibiotic regimen was adjusted to meropenem (1 g i.v. q8h) and vancomycin (1 g i.v. q12h).", + "The pain, redness, and swelling of the perianal area and left upper thigh continued to be relieved.", + "MRI indicated that the soft tissue of the left thigh was obviously thickened.", + "No obvious abnormal signal between/in the muscle and bone tissue was detected.", + "Another operation was performed 12 days after the second debridement.", + "The VSD equipment was removed.", + "The wound was closed.", + "Blood examination on the 3rd and 5th days postoperatively showed no inflammation.", + "Anti-infective treatment was stopped.", + "The patient was discharged at 27 days of admission.", + "The patient recovered well without adverse complaints at the time of 1-month follow-up." + ], + "summary": "Here, we report the case of a 53-year-old patient who was admitted to the hospital for a gas-producing perianal abscess. The patient was managed with ceftizoxime and ornidazole and then received debridement and drainage at the lesion on the second day after admission. The bacterial cultures of the patient isolates from the debridement showed a coinfection of Escherichia coli and Enterococcus faecium. Although perianal redness and swelling subsided obviously after the surgery, the patient was febrile to 38.3℃ with his left upper thigh red and swollen, aggravated with tenderness and crepitus. Considering insufficient debridement and the risk of incorrect identification of pathogens, a second debridement and drainage were performed 4 days after the primary operation, and 16S rDNA sequencing of the isolates implicated Clostridium perfringens infection. Given the discrepancies in diagnostic results and the treatment outcomes, Enterococcus faecium was identified as sample contamination, and a diagnosis of coinfection of Clostridium perfringens and Escherichia coli in gas-producing perianal abscess was confirmed. The patient was then successfully treated with meropenem and vancomycin and was discharged at 27 days of admission.", + "summary_subclaims": [ + "The patient was a 53-year-old individual.", + "The patient was admitted to the hospital for a gas-producing perianal abscess.", + "The patient was managed with ceftizoxime and ornidazole.", + "Debridement and drainage at the lesion were performed on the second day after admission.", + "Bacterial cultures of the patient isolates from the debridement showed a coinfection of Escherichia coli and Enterococcus faecium.", + "Perianal redness and swelling subsided obviously after the surgery.", + "The patient was febrile to 38.3℃ with his left upper thigh red and swollen.", + "The left upper thigh swelling was aggravated with tenderness and crepitus.", + "A second debridement and drainage were performed 4 days after the primary operation.", + "16S rDNA sequencing of the isolates implicated Clostridium perfringens infection.", + "Enterococcus faecium was identified as sample contamination.", + "A diagnosis of coinfection of Clostridium perfringens and Escherichia coli in gas-producing perianal abscess was confirmed.", + "The patient was successfully treated with meropenem and vancomycin.", + "The patient was discharged at 27 days of admission." + ] + }, + { + "id": "multiclinsum_test_128_en.txt", + "fulltext": "A 19-year-old female had a subcutaneous implant placed one year prior to a visit to her physician. During the implantation of the device, abnormal cutaneous bleeding was noted. After the physician was unable to locate the implant, an ultrasound was performed. The ultrasound was unable to locate the contraceptive device. A thoracic CT scan revealed that the implant had migrated into the lower left lobular segmental pulmonary artery. The patient reported no symptoms related to the migration of the implant. After a multidisciplinary consultation involving a cardiac surgeon, anaesthesiologists, a gynaecologist, a cardiologist, and an interventional radiologist, an endovascular approach was considered. The patient underwent a preoperative consultation with a gynaecologist, an anaesthesiologist, and an interventional radiologist to explain the removal procedure and the known risks of pulmonary arterial catheterization. The procedure planning included the de-sterilization of a Nexplanon® to assess its flexibility. The team decided to perform the removal under bi-planar fluoroscopic guidance, as routinely done in our department for foreign body retrieval. Both right and left anterior obliquities were chosen to ideally expose the contraceptive implant . The procedure was conducted under general anaesthesia. Following a right femoral venous puncture under ultrasound guidance, a long 8F NeuronMax® introducer (Penumbra, Inc., Alameda, CA, USA) was placed under fluoroscopic guidance into the right inferior vena cava. The left pulmonary artery was catheterized using a 5F 145° angled Pigtail catheter (Merit Medical, UT, USA). An angiogram confirmed the position of the contraceptive implant, without thrombosis. After guide exchange with a stiff guide wire (Terumo, Tokyo, Japan), the NeuronMax® catheter was subsequently advanced to the left pulmonary artery, just upstream of the foreign body. A 25-mm diameter loop snare (One Snare®, Merit Medical, UT, USA) was deployed. Once captured, the contraceptive implant was removed under fluoroscopic guidance without removing it into the NeuronMax® catheter. The procedure lasted 60 min. The fluoroscopic dose was 261 mGy, and fluoroscopy time was 10 min. The following day, a thoracic CT scan showed no procedure-related complications, and the patient was discharged. The patient did not receive any medical treatment before, during, or after the procedure.", + "fulltext_subclaims": [ + "A 19-year-old female had a subcutaneous implant placed one year prior to a visit to her physician.", + "During the implantation of the device, abnormal cutaneous bleeding was noted.", + "After the physician was unable to locate the implant, an ultrasound was performed.", + "The ultrasound was unable to locate the contraceptive device.", + "A thoracic CT scan revealed that the implant had migrated into the lower left lobular segmental pulmonary artery.", + "The patient reported no symptoms related to the migration of the implant.", + "After a multidisciplinary consultation involving a cardiac surgeon, anaesthesiologists, a gynaecologist, a cardiologist, and an interventional radiologist, an endovascular approach was considered.", + "The patient underwent a preoperative consultation with a gynaecologist, an anaesthesiologist, and an interventional radiologist to explain the removal procedure and the known risks of pulmonary arterial catheterization.", + "The procedure planning included the de-sterilization of a Nexplanon® to assess its flexibility.", + "The team decided to perform the removal under bi-planar fluoroscopic guidance.", + "Both right and left anterior obliquities were chosen to ideally expose the contraceptive implant.", + "The procedure was conducted under general anaesthesia.", + "Following a right femoral venous puncture under ultrasound guidance, a long 8F NeuronMax® introducer was placed under fluoroscopic guidance into the right inferior vena cava.", + "The left pulmonary artery was catheterized using a 5F 145° angled Pigtail catheter.", + "An angiogram confirmed the position of the contraceptive implant, without thrombosis.", + "After guide exchange with a stiff guide wire, the NeuronMax® catheter was subsequently advanced to the left pulmonary artery, just upstream of the foreign body.", + "A 25-mm diameter loop snare was deployed.", + "Once captured, the contraceptive implant was removed under fluoroscopic guidance without removing it into the NeuronMax® catheter.", + "The procedure lasted 60 min.", + "The fluoroscopic dose was 261 mGy.", + "Fluoroscopy time was 10 min.", + "The following day, a thoracic CT scan showed no procedure-related complications.", + "The patient was discharged.", + "The patient did not receive any medical treatment before, during, or after the procedure." + ], + "summary": "A 19-year-old female presented no sensation of a contraceptive implant in her arm which had been placed one year prior. A CT scan confirmed that the implant had migrated into the left lower segmentary pulmonary artery. After a multidisciplinary meeting, an endovascular approach was attempted. Following right femoral venous access, a 8F NeuronMax® introducer was placed into the left pulmonary artery under fluoroscopic guidance. The contraceptive device was removed using a 25-mm loop snare, with a proximal capture technique. The patient was discharged the following day, with no reported complications.", + "summary_subclaims": [ + "The patient was a 19-year-old female.", + "The contraceptive implant had been placed one year prior.", + "The patient reported no sensation of the contraceptive implant.", + "A CT scan confirmed the implant had migrated into the left lower segmentary pulmonary artery.", + "An endovascular approach was attempted.", + "A 8F NeuronMax® introducer was placed into the left pulmonary artery.", + "The contraceptive device was removed using a 25-mm loop snare.", + "The patient was discharged the following day.", + "The patient had no reported complications." + ] + }, + { + "id": "multiclinsum_test_166_en.txt", + "fulltext": "A 33-year-old Saudi male presented to the surgical clinic of King Khalid Hospital Najran Saudi Arabia, with a slowly growing painless lump in the right buttock for about six months. The patient complained of fatigue and recurrent episodes of low grade fever. On examination, there was a soft and cystic, non-tender lump on the right buttock measuring about 4×4cm . The overlying skin was normal without any punctum or discharge. Except for eosinophilia in the complete blood count (CBC), the rest of baseline blood tests and chest X-ray were normal. The enzyme-linked immune-absorbent assay (ELISA) was positive for the Echinococcal granulosis antigens. Computed tomography (CT) scan of the concerned region showed an intact cyst with thin enhancing rim containing homogenous fluid contents . Later on, further inquiry from the patient confirmed his direct contact with the infected sheep a few months before. Surgical exploration of the mass was undertaken under general anesthesia. After appropriate packing of the surgical field with 20% hypertonic saline solution, the lump was completely excised . The lump was found to be a primary muscular hydatid cyst, attached to the right gluteus medius muscle, with multiple daughter cysts . The histopathology report detailed a circumscribed multilocular cystic lesion with a 2-mm thick fibrous wall . The cyst contained clear fluid with sand-like pasty material and calcified bodies. There were multiple daughter cysts with the same histological architecture. Following the surgical procedure, albendazole 10mg/kg/day was advised for 3 months to prevent recurrence. The patient had an uneventful recovery and was discharged home in a satisfactory condition.", + "fulltext_subclaims": [ + "The patient is a 33-year-old Saudi male.", + "The patient presented with a slowly growing painless lump in the right buttock for about six months.", + "The patient complained of fatigue.", + "The patient had recurrent episodes of low grade fever.", + "On examination, there was a soft and cystic, non-tender lump on the right buttock measuring about 4×4cm.", + "The overlying skin was normal without any punctum or discharge.", + "The complete blood count showed eosinophilia.", + "The enzyme-linked immune-absorbent assay was positive for the Echinococcal granulosis antigens.", + "Computed tomography showed an intact cyst with thin enhancing rim containing homogenous fluid contents.", + "The patient had direct contact with infected sheep a few months before.", + "Surgical exploration of the mass was undertaken under general anesthesia.", + "The surgical field was packed with 20% hypertonic saline solution.", + "The lump was completely excised.", + "The lump was found to be a primary muscular hydatid cyst attached to the right gluteus medius muscle.", + "The cyst contained multiple daughter cysts.", + "The histopathology report detailed a circumscribed multilocular cystic lesion with a 2-mm thick fibrous wall.", + "The cyst contained clear fluid with sand-like pasty material and calcified bodies.", + "There were multiple daughter cysts with the same histological architecture.", + "Albendazole 10mg/kg/day was advised for 3 months to prevent recurrence.", + "The patient had an uneventful recovery.", + "The patient was discharged home in a satisfactory condition." + ], + "summary": "The present case report describes a 33-year-old Saudi male with a painless swelling in the right buttock which turned out to be a primary hydatid disease of the soft tissue. The lump was successfully excised surgically and the patient had an uneventful discharge.", + "summary_subclaims": [ + "The patient is a 33-year-old Saudi male.", + "The patient had a painless swelling in the right buttock.", + "The swelling was a primary hydatid disease of the soft tissue.", + "The lump was successfully excised surgically.", + "The patient had an uneventful discharge." + ] + }, + { + "id": "multiclinsum_test_2398_en.txt", + "fulltext": "A 72-year-old man was addressed to the nephrology department for acute kidney injury with increased creatininemia at 2.2 mg/dL (N: 0.72–1.17) corresponding to an estimated glomerular filtration rate (eGFR) of 30 mL/min/1.73 m2 according to the CKD-EPI formula. He was asymptomatic. He had no personal or family history of kidney disease. He did not travel, had no allergies, and had no known contact with ill patients. He was not taking any nonsteroidal anti-inflammatory drugs. His medical history comprised of pleural tuberculosis treated 20 years before, well controlled hypertension under treatment with calcium antagonists and glaucoma treated by monthly intravitreal injections of bevacizumab in the past 6 months. Physical examination and blood pressure were normal. There was no swelling. Laboratory investigations did not show any sign of TMA, with normal haemoglobin and platelet count. Immunological testing was positive only for antiphospholipid antibodies. Infectious serology was negative. The urinalysis showed no haematuria but increase of albuminuria from 2.9 to 226 mg/g of creatinine (N: <30). Urine cultures were negative. Kidney ultrasound was normal. A renal biopsy performed two weeks after showed ten glomeruli. Two of them were obsolescent glomeruli with complete glomerulosclerosis. The other glomeruli demonstrated thickening of capillary wall . There were segmental glomerular capillary microaneurysms, filled with pale material, and segmental hyaline thickening of the glomerular basement membrane . Silver staining showed some double contours . Mild focal interstitial fibrosis and tubular atrophy with a mononuclear cells infiltrate were seen. Immunofluorescence for IgA, IgG, IgM, C1q, kappa, and lambda was negative. However, C3 immunofluorescence showed a sparse endothelial positivity in arterioles (not shown). On electron microscopy, the endothelial cells showed irregularities, and focal loss of fenestrations. Subendothelial space expansion by electron-lucent material was visible . This was consistent with signs of endothelial injury. Intravitreal injections of anti-VEGF were suspended. Four months after withdrawal, serum creatinine was of 1.20 mg/dL, and albuminuria normalized, supporting our hypothesis of intravitreal anti-VEGF induced renal microangiopathy. One year after bevacizumab was stopped, serum creatinine was of 0.95 mg/dL, and urinary albumin-creatinine ratio was of 3.3 mg/g. The patient did not present any thromboembolic event.", + "fulltext_subclaims": [ + "The patient was a 72-year-old man.", + "He was addressed to the nephrology department for acute kidney injury.", + "His serum creatinine was 2.2 mg/dL.", + "The estimated glomerular filtration rate was 30 mL/min/1.73 m2 according to the CKD-EPI formula.", + "He was asymptomatic.", + "He had no personal or family history of kidney disease.", + "He was not taking any nonsteroidal anti-inflammatory drugs.", + "His medical history included pleural tuberculosis treated 20 years before.", + "He had well-controlled hypertension under treatment with calcium antagonists.", + "He had glaucoma treated by monthly intravitreal injections of bevacizumab in the past 6 months.", + "Physical examination and blood pressure were normal.", + "There was no swelling.", + "Laboratory investigations did not show any sign of TMA.", + "Immunological testing was positive only for antiphospholipid antibodies.", + "Infectious serology was negative.", + "Urinalysis showed no haematuria.", + "Albuminuria increased from 2.9 to 226 mg/g of creatinine.", + "Urine cultures were negative.", + "Kidney ultrasound was normal.", + "A renal biopsy performed two weeks after showed ten glomeruli.", + "Two glomeruli were obsolescent with complete glomerulosclerosis.", + "The other glomeruli demonstrated thickening of capillary wall.", + "There were segmental glomerular capillary microaneurysms filled with pale material.", + "Segmental hyaline thickening of the glomerular basement membrane was seen.", + "Silver staining showed some double contours.", + "Mild focal interstitial fibrosis and tubular atrophy with a mononuclear cells infiltrate were seen.", + "Immunofluorescence for IgA, IgG, IgM, C1q, kappa, and lambda was negative.", + "C3 immunofluorescence showed a sparse endothelial positivity in arterioles.", + "On electron microscopy, the endothelial cells showed irregularities.", + "Focal loss of fenestrations was visible.", + "Subendothelial space expansion by electron-lucent material was visible.", + "This was consistent with signs of endothelial injury.", + "Intravitreal injections of anti-VEGF were suspended.", + "Four months after withdrawal, serum creatinine was 1.20 mg/dL.", + "Albuminuria normalized four months after withdrawal.", + "One year after bevacizumab was stopped, serum creatinine was 0.95 mg/dL.", + "The urinary albumin-creatinine ratio was 3.3 mg/g one year after bevacizumab was stopped.", + "The patient did not present any thromboembolic event." + ], + "summary": "A 72-year-old man was addressed for acute kidney injury with proteinuria. He was under treatment with intravitreal injections of bevacizumab for glaucoma. Kidney biopsy was performed and electron microscopy showed signs of early stages of glomerular microangiopathy. Bevacizumab was discontinued resulting in the improvement of renal function and albuminuria.", + "summary_subclaims": [ + "A 72-year-old man was addressed for acute kidney injury with proteinuria.", + "He was under treatment with intravitreal injections of bevacizumab for glaucoma.", + "Kidney biopsy was performed.", + "Electron microscopy showed signs of early stages of glomerular microangiopathy.", + "Bevacizumab was discontinued.", + "Discontinuation of bevacizumab resulted in the improvement of renal function.", + "Discontinuation of bevacizumab resulted in the improvement of albuminuria." + ] + }, + { + "id": "multiclinsum_test_1691_en.txt", + "fulltext": "A 75-year old Caucasian man with a long-standing history of tophaceous gout and several recurrent episodes of arthritis during the past five years presented with a large, painful, ulcerated tophus located on the first metatarsophalangeal joint of his left foot to our emergency department. He had intentionally interrupted treatment with allopurinol four months previously; however, he did not report any recent deviations from his standard diet, any alcohol abuse or diuretic treatment. Five days before presenting to the emergency department, a tophus on the first toe of his left foot had become painful, red and swollen. He tried a course of non-steroidal anti-inflammatory drugs (NSAIDs) without improvement. Ten hours before seeking medical assistance, the tophus burst releasing a viscous, chalk-like material.\nOn physical examination he had a mild fever of 37.8°C. A greyish, voluminous and ulcerated nodule containing chalky material was located on the first metatarsophalangeal joint of his left foot . Further examination revealed multiple other tophi overlying the first and second metacarpophalangeal joints of his left hand and the interphalangeal joints of his right hand , wrists, elbows , ankles, interphalangeal and metatarsophalangeal joints of the feet and heels . Two smaller ulcerated tophi were also seen on the fingertip of the left thumb and over the first interphalangeal joint of the right foot. Many joints were also deformed. The first metatarsophalangeal joint of his left foot was totally nonfunctional.\nLaboratory workup revealed leukocytosis (14.524/mm3), elevated C-reactive protein (7.21 mg/dl) and elevated serum uric acid (14 mg/dl). Radiographs of the foot showed soft tissue swelling and total destruction of the first metatarsophalangeal joint . Moderate periarticular alterations were also observed in the other joints of the foot. Cultures from the ulcerated tophus were negative. Antibiotic treatment with ciprofloxacin (800 mg/day) and intravenous administration of NSAIDs (lornoxicam 16 mg/day) was initiated.\nDue to the extraordinary size of the ulcer and the complete destruction of the underlying joint, amputation of the left foot was considered. However, before resorting to this solution, a surgical debridement with lavage of the joint was performed. Debridement was also performed on the minor ulcers. Five days after admission treatment with allopurinol (300 mg/day) was initiated. The patient improved clinically and was discharged two days later. For the next 33 days foam silver-containing wound dressing (CELLOSORB® Ag) and heterologous lyophilized collagen (BIOPAD®, equine collagen) were used on the largest of the three ulcers, on an outpatient basis, while efforts were made to keep serum uric acid levels within normal limits. All three ulcers healed completely within eight, 10 and 40 days after initial presentation, respectively . Six months after treatment, he remains symptom free, although he still refuses to comply with the prescribed uric acid lowering regimen and rejects any further surgical intervention.", + "fulltext_subclaims": [ + "The patient is a 75-year-old Caucasian man.", + "He has a long-standing history of tophaceous gout.", + "He has had several recurrent episodes of arthritis during the past five years.", + "He presented with a large, painful, ulcerated tophus located on the first metatarsophalangeal joint of his left foot.", + "He had intentionally interrupted treatment with allopurinol four months previously.", + "He did not report any recent deviations from his standard diet.", + "He did not report any alcohol abuse.", + "He did not report any diuretic treatment.", + "Five days before presenting to the emergency department, a tophus on the first toe of his left foot had become painful, red and swollen.", + "He tried a course of non-steroidal anti-inflammatory drugs (NSAIDs) without improvement.", + "Ten hours before seeking medical assistance, the tophus burst releasing a viscous, chalk-like material.", + "On physical examination, he had a mild fever of 37.8°C.", + "A greyish, voluminous and ulcerated nodule containing chalky material was located on the first metatarsophalangeal joint of his left foot.", + "Further examination revealed multiple other tophi overlying the first and second metacarpophalangeal joints of his left hand.", + "Further examination revealed multiple other tophi overlying the interphalangeal joints of his right hand.", + "Further examination revealed multiple other tophi overlying the wrists.", + "Further examination revealed multiple other tophi overlying the elbows.", + "Further examination revealed multiple other tophi overlying the ankles.", + "Further examination revealed multiple other tophi overlying the interphalangeal and metatarsophalangeal joints of the feet.", + "Further examination revealed multiple other tophi overlying the heels.", + "Two smaller ulcerated tophi were also seen on the fingertip of the left thumb.", + "Two smaller ulcerated tophi were also seen on the first interphalangeal joint of the right foot.", + "Many joints were also deformed.", + "The first metatarsophalangeal joint of his left foot was totally nonfunctional.", + "Laboratory workup revealed leukocytosis (14.524/mm3).", + "Laboratory workup revealed elevated C-reactive protein (7.21 mg/dl).", + "Laboratory workup revealed elevated serum uric acid (14 mg/dl).", + "Radiographs of the foot showed soft tissue swelling.", + "Radiographs of the foot showed total destruction of the first metatarsophalangeal joint.", + "Moderate periarticular alterations were also observed in the other joints of the foot.", + "Cultures from the ulcerated tophus were negative.", + "Antibiotic treatment with ciprofloxacin (800 mg/day) was initiated.", + "Intravenous administration of NSAIDs (lornoxicam 16 mg/day) was initiated.", + "Due to the extraordinary size of the ulcer and the complete destruction of the underlying joint, amputation of the left foot was considered.", + "Before resorting to amputation, a surgical debridement with lavage of the joint was performed.", + "Debridement was also performed on the minor ulcers.", + "Five days after admission, treatment with allopurinol (300 mg/day) was initiated.", + "The patient improved clinically and was discharged two days later.", + "For the next 33 days, foam silver-containing wound dressing (CELLOSORB® Ag) and heterologous lyophilized collagen (BIOPAD®, equine collagen) were used on the largest of the three ulcers.", + "Efforts were made to keep serum uric acid levels within normal limits.", + "All three ulcers healed completely within eight, 10 and 40 days after initial presentation, respectively.", + "Six months after treatment, he remains symptom free.", + "He still refuses to comply with the prescribed uric acid lowering regimen.", + "He rejects any further surgical intervention." + ], + "summary": "We report the case of a 75-year-old Caucasian man with tophaceous multiarticular gout, soft-tissue involvement and ulcerated tophi on the first metatarsophalangeal joint of the left foot, on the first interphalangeal joint of the right foot and on the left thumb.", + "summary_subclaims": [ + "The patient is a 75-year-old man.", + "The patient is Caucasian.", + "The patient has tophaceous multiarticular gout.", + "The patient has soft-tissue involvement.", + "The patient has ulcerated tophi on the first metatarsophalangeal joint of the left foot.", + "The patient has ulcerated tophi on the first interphalangeal joint of the right foot.", + "The patient has ulcerated tophi on the left thumb." + ] + }, + { + "id": "multiclinsum_test_1463_en.txt", + "fulltext": "A 52-year-old female patient with OI had recently injured her left knee, rupturing her anterior cruciate ligament (ACL). She had pre-existing degenerative changes in her right knee with a deficient medical collateral ligament (MCL) of clinical grade 3, which had been symptomatic for 2 years prior to her fall . We opted to perform a right total knee replacement before addressing the left knee injury. This would provide her with an immediate stable right limb prior to addressing her left knee.\nA Nextgen Rotating Hinge Knee (ZimmerBiomet®) hinged prosthesis was used because of her incompetent MCL . The smallest components available were used because of her small anatomical bony dimensions. The OI population tend to experience growth retardation and standard implant sizes are generally over-sized for these patients. This necessitates pre-operative planning in the form of templating to ensure the specific implant sizes are available for the patient. In the absence of such implants, patient-specific implants and cutting guides should be considered for outlier cases . The initial postoperative course was uneventful. The patient mobilised slowly though. She had poor flexion at 6 weeks and a gentle manipulation was performed cognizant of the inherent dangers. She is currently at 2-year post-op with full extension and flexion to 110 degrees. The patient-reported outcome measures improved as follows: her visual analogue score (VAS) was 7/10, 3/10 and 2/10 before, 6 and 24 months after surgery respectively. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) knee score was 36.4, 59.4 and 86.4 before, 6 and 24 months after surgery respectively. She continued to wear a brace on left knee as she was reluctant to undergo an ACL reconstruction.", + "fulltext_subclaims": [ + "The patient is a 52-year-old female with osteogenesis imperfecta.", + "She had recently injured her left knee, rupturing her anterior cruciate ligament.", + "She had pre-existing degenerative changes in her right knee.", + "She had a grade 3 deficient medial collateral ligament in her right knee.", + "The medial collateral ligament deficiency had been symptomatic for 2 years prior to her fall.", + "A right total knee replacement was performed before addressing the left knee injury.", + "A Nextgen Rotating Hinge Knee hinged prosthesis was used.", + "The smallest components available were used because of her small anatomical bony dimensions.", + "The OI population tend to experience growth retardation.", + "Standard implant sizes are generally over-sized for OI patients.", + "Pre-operative planning in the form of templating is necessary to ensure specific implant sizes are available.", + "In the absence of specific implants, patient-specific implants and cutting guides should be considered for outlier cases.", + "The initial postoperative course was uneventful.", + "The patient mobilised slowly.", + "She had poor flexion at 6 weeks.", + "A gentle manipulation was performed.", + "She is currently 2 years post-op.", + "She has full extension and flexion to 110 degrees.", + "Her visual analogue score was 7/10 before surgery.", + "Her visual analogue score was 3/10 at 6 months after surgery.", + "Her visual analogue score was 2/10 at 24 months after surgery.", + "Her WOMAC knee score was 36.4 before surgery.", + "Her WOMAC knee score was 59.4 at 6 months after surgery.", + "Her WOMAC knee score was 86.4 at 24 months after surgery.", + "She continued to wear a brace on her left knee.", + "She was reluctant to undergo an ACL reconstruction." + ], + "summary": "Presented here is a total knee replacement performed on a 52-year-old patient with osteogenesis imperfecta (OI) who injured her left knee and ruptured her anterior cruciate ligament. Her right knee suffered from severe degenerative changes with an incompetent medial collateral ligament. It was decided to replace the right knee before addressing the left knee injury. A hinged revision prosthesis was used. The smallest components available were used because of the small anatomical bony dimensions.", + "summary_subclaims": [ + "The patient is a 52-year-old woman.", + "The patient has osteogenesis imperfecta.", + "The patient injured her left knee.", + "The patient ruptured her anterior cruciate ligament.", + "The right knee had severe degenerative changes.", + "The right knee had an incompetent medial collateral ligament.", + "It was decided to replace the right knee before addressing the left knee injury.", + "A hinged revision prosthesis was used.", + "The smallest components available were used." + ] + }, + { + "id": "multiclinsum_test_2545_en.txt", + "fulltext": "A 21-year-old Caucasian patient assigned male at birth presented with 2 days of severe rectal, abdominal, testicular pain, and loose stools. He reported history of hemorrhoids with intermittent bright red blood per rectum over 9 months. History was notable for prior appendectomy and allergies to penicillin (rash), pollen, and several raw fruits/vegetables. He took emtricitabine/tenofovir/disoproxil fumarate for HIV pre-exposure prophylaxis. He recently received prophylactic chlamydia treatment and one dose of the mpox vaccine series approximately 1 month prior to presentation. He was a student. He had a non-monogamous relationship with a male partner and reported receptive and insertive anal intercourse with inconsistent condom use and intermittent use of sex toys, including anal beads. He had recently traveled to Hawaii, California, Michigan, and Maine in the summer. Two years prior to presentation he had traveled to Japan. He had multiple pet dogs and cats. He reported having a younger sibling with lymphomatoid papulosis.\nIn the emergency room, vital signs were normal. On examination, he had tender bilateral inguinal lymphadenopathy, mild right lateral testicular tenderness when palpated, and tenderness in the right lower abdominal quadrant and suprapubic region. No hemorrhoids or anal fissures were visualized. Initial workup included complete blood count remarkable for low platelet count of 125,000 cells/µL (reference: 150,000–420,000 cells/µL) and increased atypical lymphocytes at 3% (reference: 0–1%); white blood cell count was normal at 6000 cells/µL (reference: 3800–10,800 cells/µL). Computed tomography (CT) of the abdomen/pelvis showed mesorectal lymphadenopathy and rectal wall thickening with circumferential fat stranding consistent with acute proctitis, without abnormalities of the prostate, testicle, or epididymis. Basic metabolic panel, urinalysis, and throat/urine/rectal gonorrhea/chlamydia testing were normal. He received ketorolac for pain and was started on ceftriaxone/metronidazole/doxycycline prior to medical admission for further management of proctitis.\nHe was promptly switched from ceftriaxone to ciprofloxacin after a scrotal/testicular ultrasound (performed 12 hours after the CT abdomen) confirmed left epididymitis. He was transitioned from ceftriaxone to ciprofloxacin to cover for Pseudomonas, which is a common bacterial organism that can be associated with epididymitis. On hospitalization day 2, metronidazole and doxycycline were discontinued, and acyclovir was started for empiric herpes simplex virus (HSV) coverage. Additional infectious workup was notable for detection of CMV on initial quantitative polymerase chain reaction (PCR) testing of the blood, albeit with quantitation < 137 IU/mL (reference: < 137 IU/mL). CMV immunoglobulin M (IgM) was negative, as were the following studies: Monospot testing, hepatitis panel (including hepatitis C antibody), treponemal antibody, rectal mpox/HSV/varicella zoster virus (VZV) PCRs, repeat gonorrhea/chlamydia (urine/rectal/throat), respiratory viral panel, serum HIV PCR, serum enterovirus and adenovirus PCRs, tick-borne serology panel, and urine mycoplasma/ureaplasma PCR. He had stool studies performed including Helicobacter pylori stool antigen, Clostridium difficile enzyme immunoassay, stool ova and parasites, stool pathogen PCR panel (Campylobacter, Salmonella, Shigella, Yersinia enterocolitica, Shiga Toxin 1 and 2, Vibrio), and stool Giardia antigen that were negative. Calprotectin had initially been sent due to concern for possible inflammatory bowel disease and was noted to be elevated to 1110 µg/g (reference: < 50 µg/g).\nOver a period of days, he also developed myalgias and arthralgias. Due to lack of improvement in rectal pain over a period of days, colorectal surgery and gastroenterology advised additional workup with colonoscopy. On hospital day 7, colonoscopy was remarkable for irregular ulcerations with exudate in the distal rectum, mild-to-moderate patchy erythema in the more proximal rectum, and mild mucosal edema in the sigmoid colon. Biopsies were taken from the terminal ileum, colon, and rectum and sent for tissue culture and pathology. Rectal pathology demonstrated findings consistent with CMV-associated proctitis . These findings included patchy inflammatory changes in the rectum with ulceration, ischemic-type changes, and prominent apoptosis within crypts. CMV inclusions were seen in the stroma and focal epithelial cells, and had positive CMV immunostaining. Colonic and ileal mucosa samples had no significant abnormalities and did not show findings of inflammatory bowel disease. Immunohistochemistry stains for Treponema spp. and HSV were negative.\nValganciclovir was initiated for treatment of CMV proctitis; all other antibiotic/antiviral treatments were discontinued. Repeat Epstein–Barr virus (EBV)/CMV quantitative viral load testing and serologies were sent. The EBV serum panel result was consistent with prior infection. The initial CMV IgG was mildly positive at 0.28 U/mL (reference: < 0.20 U/mL). Add-on studies from hospital day 4 showed that CMV IgG had been negative (reference: < 0.20 U/mL), while CMV IgM had become positive at 70.60 AU/mL (reference: < 8 AU/mL) . On hospital day 10, CMV IgG and IgM were both positive at 1.4 U/mL (reference: < 0.20 U/mL) and > 240 AU/mL (reference: < 8 AU/mL), respectively. Given the evolution in serology with rising CMV IgM titers and development of positive IgG over time, the clinical presentation was thought to be consistent with acute primary CMV infection. A T lymphocyte subset panel was also sent to determine CD4 count and evaluate for possible undiagnosed immunodeficiency. He had a low-normal CD4 count of 513 cells/µL (reference: 490–1740 cells/µL), elevated CD8 count of 1867 cells/µL (reference: 153–980 cells/µL), and a low CD4/CD8 ratio at 0.27 (reference: 0.73–5.86). A decreased CD4/CD8 ratio can be seen with viral infections, including CMV infection.\nThe hospital course was also complicated by mildly elevated liver transaminases that trended upward to peak of 189 U/L (reference: 10–35 U/L), prior to discharge on day 14. CT of the abdomen and pelvis with intravenous contrast had not shown any hepatobiliary pathology, and a viral hepatitis panel was negative. The transaminitis was ultimately attributed to CMV infection.\nThe patient was discharged with a 3-week course of valganciclovir and recommended to follow-up with primary care, infectious diseases, and immunology physicians. He was counseled to abstain from sexual intercourse until treatment completion. At a follow-up visit with the infectious diseases physician 3 weeks later, the patient had significantly improved with near complete abatement of rectal and testicular pain, myalgias, and arthralgias. Repeat liver function tests 2 weeks post-hospital discharge were normal.", + "fulltext_subclaims": [ + "The patient was a 21-year-old Caucasian man assigned male at birth.", + "He had 2 days of severe rectal, abdominal, and testicular pain.", + "He had loose stools.", + "He reported a history of hemorrhoids with intermittent bright red blood per rectum over 9 months.", + "He had a prior appendectomy.", + "He had allergies to penicillin, pollen, and several raw fruits/vegetables.", + "He took emtricitabine/tenofovir/disoproxil fumarate for HIV pre-exposure prophylaxis.", + "He recently received prophylactic chlamydia treatment.", + "He had one dose of the mpox vaccine series approximately 1 month prior to presentation.", + "He had a non-monogamous relationship with a male partner.", + "He reported receptive and insertive anal intercourse with inconsistent condom use.", + "He had recently traveled to Hawaii, California, Michigan, and Maine in the summer.", + "He had multiple pet dogs and cats.", + "He had a younger sibling with lymphomatoid papulosis.", + "In the emergency room, vital signs were normal.", + "He had tender bilateral inguinal lymphadenopathy.", + "He had mild right lateral testicular tenderness when palpated.", + "He had tenderness in the right lower abdominal quadrant and suprapubic region.", + "No hemorrhoids or anal fissures were visualized.", + "Initial workup showed a low platelet count of 125,000 cells/µL.", + "Initial workup showed increased atypical lymphocytes at 3%.", + "Computed tomography showed mesorectal lymphadenopathy.", + "Computed tomography showed rectal wall thickening with circumferential fat stranding.", + "Computed tomography findings were consistent with acute proctitis.", + "Basic metabolic panel, urinalysis, and gonorrhea/chlamydia testing were normal.", + "He received ketorolac for pain.", + "He was started on ceftriaxone/metronidazole/doxycycline prior to medical admission.", + "A scrotal/testicular ultrasound confirmed left epididymitis.", + "He was switched from ceftriaxone to ciprofloxacin.", + "Ciprofloxacin was started to cover for Pseudomonas.", + "Metronidazole and doxycycline were discontinued on hospitalization day 2.", + "Acyclovir was started for empiric HSV coverage.", + "CMV was detected on initial quantitative PCR testing of the blood.", + "CMV IgM was negative.", + "Monospot testing was negative.", + "Hepatitis panel was negative.", + "Rectal mpox/HSV/VZV PCRs were negative.", + "Stool studies were negative.", + "Calprotectin was elevated to 1110 µg/g.", + "He developed myalgias and arthralgias.", + "Colorectal surgery and gastroenterology advised additional workup with colonoscopy.", + "Colonoscopy showed irregular ulcerations with exudate in the distal rectum.", + "Rectal pathology demonstrated findings consistent with CMV-associated proctitis.", + "CMV inclusions were seen in the stroma and focal epithelial cells.", + "Colonic and ileal mucosa samples had no significant abnormalities.", + "Valganciclovir was initiated for treatment of CMV proctitis.", + "Repeat EBV/CMV quantitative viral load testing was sent.", + "The EBV serum panel result was consistent with prior infection.", + "The initial CMV IgG was mildly positive at 0.28 U/mL.", + "CMV IgG had been negative on hospital day 4.", + "CMV IgM became positive at 70.60 AU/mL on hospital day 4.", + "On hospital day 10, CMV IgG and IgM were both positive.", + "The clinical presentation was thought to be consistent with acute primary CMV infection.", + "A T lymphocyte subset panel was sent.", + "The CD4 count was 513 cells/µL.", + "The CD8 count was 1867 cells/µL.", + "The CD4/CD8 ratio was 0.27.", + "The transaminitis was attributed to CMV infection.", + "The patient was discharged with a 3-week course of valganciclovir.", + "He was counseled to abstain from sexual intercourse until treatment completion.", + "At a follow-up visit 3 weeks later, the patient had significantly improved.", + "Repeat liver function tests 2 weeks post-hospital discharge were normal." + ], + "summary": "A 21-year-old previously healthy Caucasian individual was admitted for severe rectal and testicular pain in the setting of proctitis and epididymitis. Serology and rectal pathology confirmed acute primary cytomegalovirus infection.", + "summary_subclaims": [ + "The individual is a 21-year-old previously healthy Caucasian.", + "The individual was admitted for severe rectal and testicular pain.", + "The individual had proctitis.", + "The individual had epididymitis.", + "Serology confirmed acute primary cytomegalovirus infection.", + "Rectal pathology confirmed acute primary cytomegalovirus infection." + ] + }, + { + "id": "multiclinsum_test_1210_en.txt", + "fulltext": "A 32-year-old man with no pertinent medical history presented to the emergency department with acute coughing up of 300 ml of bright-red blood over 3 hours following a sneezing episode. The patient was a taxi driver and had no history of cigarette smoking, alcohol drinking, upper airway complaints, chest trauma, or use of aspirin or non-steroidal anti-inflammatory drugs. Also, he denied prior hemoptysis or other pulmonary symptoms, infectious symptoms, or a family history of hemoptysis or brain aneurysms.\nHis temperature was 36.8 degrees Celsius, pulse was 88 per minute, respirations were 18 per minute, and blood pressure was 128/88 mmHg. Pulse oximetry showed an oxygen saturation of 98% in the room air. The results of physical examination were unremarkable. The complete blood count, the levels of urea nitrogen and creatinine, liver biochemistry, and coagulation profiles were also normal. Urinalysis revealed no abnormalities. A chest X-ray showed an ill-defined opacity around the left hilum and chest CT demonstrated soft-tissue opacity within the left mainstem bronchus with a needle-shaped material protruding from it. A retained tracheobronchial foreign body was suspected. Flexible fiberoptic bronchoscopy found impaction of a dental floss pick in the left main bronchus with granulation tissue formation and clotted blood over it. The object was successfully removed using biopsy forceps and no procedure-related complications, such as tracheal laceration, vocal cord injury or bleeding, were noted. After foreign body retrieval, the patient recalled having had dental floss pick ingestion 8 years earlier. He still uses dental floss picks to clean his teeth every day. He no longer had hemoptysis during his hospital stay and he was discharged a few hours later.", + "fulltext_subclaims": [ + "A 32-year-old man with no pertinent medical history presented to the emergency department with acute coughing up of 300 ml of bright-red blood over 3 hours following a sneezing episode.", + "The patient had no history of cigarette smoking.", + "The patient had no history of alcohol drinking.", + "The patient had no history of upper airway complaints.", + "The patient had no history of chest trauma.", + "The patient had no history of use of aspirin or non-steroidal anti-inflammatory drugs.", + "The patient denied prior hemoptysis.", + "The patient denied other pulmonary symptoms.", + "The patient denied infectious symptoms.", + "The patient denied a family history of hemoptysis.", + "The patient denied a family history of brain aneurysms.", + "The patient's temperature was 36.8 degrees Celsius.", + "The patient's pulse was 88 per minute.", + "The patient's respirations were 18 per minute.", + "The patient's blood pressure was 128/88 mmHg.", + "Pulse oximetry showed an oxygen saturation of 98% in the room air.", + "The results of physical examination were unremarkable.", + "The complete blood count was normal.", + "The levels of urea nitrogen and creatinine were normal.", + "Liver biochemistry was normal.", + "Coagulation profiles were normal.", + "Urinalysis revealed no abnormalities.", + "A chest X-ray showed an ill-defined opacity around the left hilum.", + "Chest CT demonstrated soft-tissue opacity within the left mainstem bronchus with a needle-shaped material protruding from it.", + "A retained tracheobronchial foreign body was suspected.", + "Flexible fiberoptic bronchoscopy found impaction of a dental floss pick in the left main bronchus with granulation tissue formation and clotted blood over it.", + "The object was successfully removed using biopsy forceps.", + "No procedure-related complications, such as tracheal laceration, vocal cord injury or bleeding, were noted.", + "After foreign body retrieval, the patient recalled having had dental floss pick ingestion 8 years earlier.", + "He still uses dental floss picks to clean his teeth every day.", + "He no longer had hemoptysis during his hospital stay.", + "He was discharged a few hours later." + ], + "summary": "We report a case of massive hemoptysis in a 32-year-old man due to a dental floss pick in the left main bronchus. Flexible fiberoptic bronchoscopy was successful in removing the foreign body.", + "summary_subclaims": [ + "The patient was a 32-year-old man.", + "The patient had massive hemoptysis.", + "The cause of the hemoptysis was a dental floss pick in the left main bronchus.", + "Flexible fiberoptic bronchoscopy was successful in removing the foreign body." + ] + }, + { + "id": "multiclinsum_test_179_en.txt", + "fulltext": "A 71-year-old male was admitted to our clinic with complaints of left shoulder pain, swelling in the left anterolateral chest wall, jaundice, weight loss, dyspnea and weakness. At three months prior to admission, he had noticed a less movable mass approximately 2 cm in diameter and then the tumor had grown rapidly, becoming increasingly painful during exertion. There was no history of expectoration, fever, or night sweats. The patient's physical examination revealed yellow discoloration of the sclerae, pitting edema up to the knees and a 5 cm × 6 cm fixed mass in the left axillary region. There was mild splenomegaly but no hepatomegaly, liver masses or ascites. Laboratory findings were as follows: sedimentation rate: 90 mm/hr; Hb: 11.5 mg/dL; WBC: 3900/mm3; Plt: 126 000/mm3; PT: 15.6 sec; INR:1.3; total protein: 6.5 g/dL (N: 6.4–8.5 g/dL); albumin: 2.2 g/dL (N: 3.4–4.8 g/dL); AST: 124 iu/L (N: 15–40); ALT: 52 iu/L (N: 10–40); ALP: 173 iu/L (N: 37–147); GGT: 213 iu/L (N:0–40); total bilirubin: 3.8 mg/dL (N: 0.1–1.2), and direct bilirubin: 1.57 mg/dL (N: 0–0.3). Hepatitis B virus surface antigen, IgG antibody to the core antigen, anti-HBe and HBV DNA with polymerase chain reaction were positive. HBe antigen, anti-Delta and serological markers of hepatitis C were negative.\nAbdominal ultrasonography showed ascites, splenomegaly and diffusely nodular and heterogeneous echogenic patterns in the liver. There was no history of chronic liver disease. Upper gastrointestinal endoscopy was normal except for esophageal varices. Computerized tomography of the thorax revealed a mass on the left anterolateral chest wall . Cytological examination of a fine needle aspirate taken from the mass was consistent with metastatic hepatocellular carcinoma . Abdominal computerized tomography detected thrombosis in the right portal vein. The liver parenchyma was diffusely heterogeneous with irregular borders and without a clear mass or infiltrating lesion. There was no lymphadenopathy on thoracic, abdominal or pelvic computerized tomography. The patient had an elevated serum alpha-feto protein (AFP) level of 60 000 ng/mL (0 – 13.6 ng/ml). Cytological examination of the liver confirmed the diagnosis of hepatocellular carcinoma. The patient was discharged on palliative treatment, and he died 21 days later.", + "fulltext_subclaims": [ + "The patient was a 71-year-old male.", + "He was admitted with complaints of left shoulder pain.", + "He had swelling in the left anterolateral chest wall.", + "He had jaundice.", + "He had weight loss.", + "He had dyspnea.", + "He had weakness.", + "Three months prior to admission, he had noticed a less movable mass approximately 2 cm in diameter.", + "The tumor had grown rapidly.", + "The tumor became increasingly painful during exertion.", + "There was no history of expectoration.", + "There was no history of fever.", + "There was no history of night sweats.", + "Physical examination revealed yellow discoloration of the sclerae.", + "Physical examination revealed pitting edema up to the knees.", + "Physical examination revealed a 5 cm × 6 cm fixed mass in the left axillary region.", + "There was mild splenomegaly.", + "There was no hepatomegaly.", + "There were no liver masses.", + "There was no ascites.", + "Sedimentation rate was 90 mm/hr.", + "Hb was 11.5 mg/dL.", + "WBC was 3900/mm3.", + "Plt was 126 000/mm3.", + "PT was 15.6 sec.", + "INR was 1.3.", + "Total protein was 6.5 g/dL.", + "Albumin was 2.2 g/dL.", + "AST was 124 iu/L.", + "ALT was 52 iu/L.", + "ALP was 173 iu/L.", + "GGT was 213 iu/L.", + "Total bilirubin was 3.8 mg/dL.", + "Direct bilirubin was 1.57 mg/dL.", + "Hepatitis B virus surface antigen was positive.", + "IgG antibody to the core antigen was positive.", + "Anti-HBe was positive.", + "HBV DNA with polymerase chain reaction was positive.", + "HBe antigen was negative.", + "Anti-Delta was negative.", + "Serological markers of hepatitis C were negative.", + "Abdominal ultrasonography showed ascites.", + "Abdominal ultrasonography showed splenomegaly.", + "Abdominal ultrasonography showed diffusely nodular and heterogeneous echogenic patterns in the liver.", + "There was no history of chronic liver disease.", + "Upper gastrointestinal endoscopy was normal except for esophageal varices.", + "Computerized tomography of the thorax revealed a mass on the left anterolateral chest wall.", + "Cytological examination of a fine needle aspirate taken from the mass was consistent with metastatic hepatocellular carcinoma.", + "Abdominal computerized tomography detected thrombosis in the right portal vein.", + "The liver parenchyma was diffusely heterogeneous with irregular borders.", + "There was no clear mass or infiltrating lesion in the liver.", + "There was no lymphadenopathy on thoracic, abdominal, or pelvic computerized tomography.", + "Serum alpha-feto protein (AFP) level was 60 000 ng/mL.", + "Cytological examination of the liver confirmed the diagnosis of hepatocellular carcinoma.", + "The patient was discharged on palliative treatment.", + "He died 21 days after discharge." + ], + "summary": "We report a patient with hepatocellular carcinoma who presented with an isolated metastatic mass on the left anterolateral chest wall in the axillary region.", + "summary_subclaims": [ + "The patient had hepatocellular carcinoma.", + "The patient presented with an isolated metastatic mass.", + "The metastatic mass was located on the left anterolateral chest wall.", + "The metastatic mass was in the axillary region." + ] + }, + { + "id": "multiclinsum_test_2574_en.txt", + "fulltext": "A 53 year old male presented with the inability to void and bloody urethral discharge after having introduced an electrical wire into his urethra for masturbation 3 hours earlier. He had made several unsuccessful attempts to remove it.\nDuring the physical examination, the two ends of the wire were observed in the urethral meatus . An x-ray of kidney, ureter, bladder (KUB) demonstrated a coiled up radiopaque wire inside the bladder . The patient was married with children and his wife accompanied him. His socioeconomic status was of upper class. It was the first time he had ever self-inflicted a foreign body in his urethra and he had no history of psychiatric illness or drug addiction. After giving his formal consent, the patient was taken to the operating room. Under general anesthesia and fluoroscopic control, an unsuccessful trial was made to pull the wire. An attempt was made to insert a 22Fr cystoscope or an 8Fr ureteroscope parallel to the wire but this was impossible due to lack of space. Then a suprapubic cystotomy was performed and the wire was removed . The patient was discharged on the third postoperative day and the urethral catheter was removed on the sixth day. He was on intravenous antibiotics for three days and on a per os regimen for another week. On the six month evaluation, the patient is well with a normal uroflow and no symptoms of urethral stricture.", + "fulltext_subclaims": [ + "A 53 year old male presented with the inability to void and bloody urethral discharge.", + "He had introduced an electrical wire into his urethra for masturbation 3 hours earlier.", + "He had made several unsuccessful attempts to remove it.", + "During the physical examination, the two ends of the wire were observed in the urethral meatus.", + "An x-ray of kidney, ureter, bladder (KUB) demonstrated a coiled up radiopaque wire inside the bladder.", + "It was the first time he had ever self-inflicted a foreign body in his urethra.", + "He had no history of psychiatric illness or drug addiction.", + "After giving his formal consent, the patient was taken to the operating room.", + "Under general anesthesia and fluoroscopic control, an unsuccessful trial was made to pull the wire.", + "An attempt was made to insert a 22Fr cystoscope or an 8Fr ureteroscope parallel to the wire but this was impossible due to lack of space.", + "Then a suprapubic cystotomy was performed and the wire was removed.", + "The patient was discharged on the third postoperative day.", + "The urethral catheter was removed on the sixth day.", + "He was on intravenous antibiotics for three days and on a per os regimen for another week.", + "On the six month evaluation, the patient is well with a normal uroflow and no symptoms of urethral stricture." + ], + "summary": "A 53-year-old male presented with the inability to void and bloody urethral discharge after having introduced an electrical wire in his urethra for masturbation 3 hours earlier. He had made several unsuccessful attempts to remove it.", + "summary_subclaims": [ + "The patient is a 53-year-old male.", + "The patient presented with the inability to void.", + "The patient had bloody urethral discharge.", + "The patient had introduced an electrical wire in his urethra for masturbation.", + "The wire was introduced 3 hours before presentation.", + "The patient had made several unsuccessful attempts to remove the wire." + ] + }, + { + "id": "multiclinsum_test_1367_en.txt", + "fulltext": "A 19-year-old female Thai patient had been diagnosed with SJIA 10 years previously and had been developing progressive proteinuria for 1 year. Her initial manifestations of SJIA were quotidian fever, polyarthritis, and pericardial effusion. Although she received pulse methylprednisolone, high-dose prednisolone, and multiple disease-modifying anti-rheumatic drugs from her previous hospital (including methotrexate, sulfasalazine, and cyclosporine A), her disease activity remained mostly active. At the age of 13 years, she was referred to Ramathibodi Hospital for proper management by a pediatric rheumatologist. Her blood samples were negative for antinuclear antibody, anti-double-stranded DNA, and HLA-B27 with normal levels of C3 (1550 μg/mL; reference range, 900–1800 μg/mL) and C4 (551 μg/mL; reference range, 100–600 μg/mL). No underlying disease was found in her family members. During the first year of follow-up at Ramathibodi Hospital, the patient was treated with 25 mg/week of etanercept [an anti-tumor necrosis factor (TNF) agent], 25 mg/week of methotrexate, 2 g/day of sulfasalazine, and 5 mg/day of prednisolone. After 6 months of treatment with etanercept, she still had severe polyarthritis. Therefore, the etanercept was discontinued, and tocilizumab, a humanized anti-interleukin (IL)-6 receptor antibody, was started at that time. However, we could not use a standard dose of tocilizumab for SJIA (8 mg/kg every 2 weeks) in the early treatment period because of the patient’s socioeconomic situation. Therefore, she received tocilizumab at a dose of 8 mg/kg every 4 weeks. She partially responded to the tocilizumab; her IL-6 level slightly declined from 1105.0 to 574.2 pg/mL 5 months after starting the treatment. Her disease course still waxed and waned. Her arthritis relapsed while receiving the tocilizumab. Therefore, pulse methylprednisolone at 1 g/month, leflunomide at 20 mg/dose, and hydroxychloroquine at 200 mg/day were gradually added to the tocilizumab regimen. The rheumatologist noticed her first episode of albuminuria when her urine albumin dipstick result was 2+. This proteinuria showed evidence of progression at her 1-year follow-up, when her urinary protein-to-creatinine ratio (UPCR) exhibited deterioration from 0.87 to 3.00 (normal ratio, <0.2). A nephrologist was then consulted to diagnose the cause of the progressive proteinuria on the background of refractory SJIA.\nOn physical examination, her vital signs were normal. She was cachectic (body weight, <3rd percentile) and had a short stature (height, <10th percentile). Her wrists, knees, and ankles were stiff and inflamed. There were no signs or symptoms of edema. Other physical findings were unremarkable. Her urinalysis showed an inactive sediment. Significant proteinuria was confirmed by a 24-h urine collection method, which showed a total urine protein of 1295 mg/day (1792 mg/1.73m2/day). Blood chemistry analysis showed hypoalbuminemia (2.68 g/dL), a normal serum cholesterol level (152 mg/dL), and a normal serum creatinine level (0.47 mg/dL). Infectious screenings were negative for hepatitis B, hepatitis C, and human immunodeficiency viral infection. Other diagnostic investigation results are listed in Table .\nThe renal tissue contained eight nonsclerotic glomeruli. The glomeruli were unremarkable. The mesangium showed focal expansion without hypercellularity. Depositions of acellular eosinophilic amorphous material were seen in the glomerular hilum, mesangium, arteriolar wall, and interstitium . The material demonstrated fuchsinophilic staining, and Congo red staining was positive with apple green birefringence under polarized microscopy. Mild tubular atrophy and interstitial fibrosis were also seen. An immunofluorescence study was negative for IgG, IgM, IgA, C3, C1q, fibrinogen, kappa, and lambda. Electron microscopy revealed randomly oriented fibrils of 8 to 10 nm in diameter in the mesangium, interstitium, and arteries . The glomerular basement membrane was unremarkable, but the podocytes showed partial foot process effacement under electron microscopy. These biopsy findings confirmed renal amyloidosis.\nBecause the amyloidosis was secondary to uncontrolled SJIA, the tocilizumab was increased from a dose of 8 mg/kg every 4 weeks to a dose of 8 mg/kg every 2 weeks. We also started enalapril at 5 mg/day (0.12 mg/kg/day) for an additional antiproteinuric effect. The other drugs were continued at their same dosages. Two months later, the patient’s Childhood Health Assessment Questionnaire Disability Index score decreased. Her UPCR had also decreased from 3.00 to 0.92, and her arthritis improved 3 months after the tocilizumab increment. At the 1-year follow-up, her UPCR had decreased to 0.23 and renal function remained stable, with a serum creatinine concentration of around 0.42 to 0.52 mg/dL. Her C-reactive protein concentration had returned to normal and her IL-6 concentration had slightly decreased. Other follow-up investigation results are listed in Table .\nA 3-mL venous blood sample was collected from the patient for DNA extraction. Next-generation sequencing was performed by SureSelect V5 using the Illumina HiSeq 4000 platform. Sanger sequencing was performed for variant verification. Variants of the MEFV gene (NM#000243, transcript ID: ENST00000219596) were analyzed. A heterozygous c.442G > C (pE148Q) mutation in the MEFV gene was identified.", + "fulltext_subclaims": [ + "The patient is a 19-year-old female Thai individual.", + "She had been diagnosed with SJIA 10 years previously.", + "She had been developing progressive proteinuria for 1 year.", + "Her initial manifestations of SJIA were quotidian fever, polyarthritis, and pericardial effusion.", + "She received pulse methylprednisolone, high-dose prednisolone, and multiple disease-modifying anti-rheumatic drugs from her previous hospital.", + "The disease-modifying anti-rheumatic drugs included methotrexate, sulfasalazine, and cyclosporine A.", + "Her disease activity remained mostly active.", + "At the age of 13 years, she was referred to Ramathibodi Hospital for proper management by a pediatric rheumatologist.", + "Her blood samples were negative for antinuclear antibody.", + "Her blood samples were negative for anti-double-stranded DNA.", + "Her blood samples were negative for HLA-B27.", + "Her C3 level was 1550 μg/mL.", + "Her C4 level was 551 μg/mL.", + "No underlying disease was found in her family members.", + "During the first year of follow-up at Ramathibodi Hospital, the patient was treated with 25 mg/week of etanercept.", + "During the first year of follow-up at Ramathibodi Hospital, the patient was treated with 25 mg/week of methotrexate.", + "During the first year of follow-up at Ramathibodi Hospital, the patient was treated with 2 g/day of sulfasalazine.", + "During the first year of follow-up at Ramathibodi Hospital, the patient was treated with 5 mg/day of prednisolone.", + "After 6 months of treatment with etanercept, she still had severe polyarthritis.", + "The etanercept was discontinued.", + "Tocilizumab was started at that time.", + "We could not use a standard dose of tocilizumab for SJIA (8 mg/kg every 2 weeks) in the early treatment period because of the patient’s socioeconomic situation.", + "She received tocilizumab at a dose of 8 mg/kg every 4 weeks.", + "Her IL-6 level slightly declined from 1105.0 to 574.2 pg/mL 5 months after starting the treatment.", + "Her disease course still waxed and waned.", + "Her arthritis relapsed while receiving the tocilizumab.", + "Pulse methylprednisolone at 1 g/month was gradually added to the tocilizumab regimen.", + "Leflunomide at 20 mg/dose was gradually added to the tocilizumab regimen.", + "Hydroxychloroquine at 200 mg/day was gradually added to the tocilizumab regimen.", + "The rheumatologist noticed her first episode of albuminuria when her urine albumin dipstick result was 2+.", + "Her urinary protein-to-creatinine ratio (UPCR) exhibited deterioration from 0.87 to 3.00.", + "A nephrologist was then consulted to diagnose the cause of the progressive proteinuria on the background of refractory SJIA.", + "On physical examination, her vital signs were normal.", + "She was cachectic (body weight, <3rd percentile).", + "Her wrists, knees, and ankles were stiff and inflamed.", + "There were no signs or symptoms of edema.", + "Other physical findings were unremarkable.", + "Her urinalysis showed an inactive sediment.", + "Significant proteinuria was confirmed by a 24-h urine collection method.", + "The 24-h urine collection showed a total urine protein of 1295 mg/day.", + "The 24-h urine collection showed a total urine protein of 1792 mg/1.73m2/day.", + "Blood chemistry analysis showed hypoalbuminemia (2.68 g/dL).", + "Her serum cholesterol level was 152 mg/dL.", + "Her serum creatinine level was 0.47 mg/dL.", + "Infectious screenings were negative for hepatitis B.", + "Infectious screenings were negative for hepatitis C.", + "Infectious screenings were negative for human immunodeficiency viral infection.", + "The renal tissue contained eight nonsclerotic glomeruli.", + "The glomeruli were unremarkable.", + "The mesangium showed focal expansion without hypercellularity.", + "Depositions of acellular eosinophilic amorphous material were seen in the glomerular hilum, mesangium, arteriolar wall, and interstitium.", + "The material demonstrated fuchsinophilic staining.", + "Congo red staining was positive with apple green birefringence under polarized microscopy.", + "Mild tubular atrophy and interstitial fibrosis were also seen.", + "An immunofluorescence study was negative for IgG, IgM, IgA, C3, C1q, fibrinogen, kappa, and lambda.", + "Electron microscopy revealed randomly oriented fibrils of 8 to 10 nm in diameter in the mesangium, interstitium, and arteries.", + "The glomerular basement membrane was unremarkable.", + "The podocytes showed partial foot process effacement under electron microscopy.", + "These biopsy findings confirmed renal amyloidosis.", + "Because the amyloidosis was secondary to uncontrolled SJIA, the tocilizumab was increased from a dose of 8 mg/kg every 4 weeks to a dose of 8 mg/kg every 2 weeks.", + "Enalapril at 5 mg/day (0.12 mg/kg/day) was started for an additional antiproteinuric effect.", + "The other drugs were continued at their same dosages.", + "Two months later, the patient’s Childhood Health Assessment Questionnaire Disability Index score decreased.", + "Her UPCR had also decreased from 3.00 to 0.92.", + "Her arthritis improved 3 months after the tocilizumab increment.", + "At the 1-year follow-up, her UPCR had decreased to 0.23.", + "Renal function remained stable, with a serum creatinine concentration of around 0.42 to 0.52 mg/dL.", + "Her C-reactive protein concentration had returned to normal.", + "Her IL-6 concentration had slightly decreased.", + "A 3-mL venous blood sample was collected from the patient for DNA extraction.", + "Next-generation sequencing was performed by SureSelect V5 using the Illumina HiSeq 4000 platform.", + "Sanger sequencing was performed for variant verification.", + "Variants of the MEFV gene (NM#000243, transcript ID: ENST00000219596) were analyzed.", + "A heterozygous c.442G > C (pE148Q) mutation in the MEFV gene was identified." + ], + "summary": "We herein report a case involving a 19-year-old female patient with difficult-to-control SJIA. She developed progressive proteinuria without clinical signs or symptoms of edema. Renal amyloidosis was diagnosed by renal pathologic examination, which demonstrated deposition of eosinophilic amorphous material in the interlobular arteries, arterioles, and interstitium. Electron microscopy showed fibrillary material deposits with a diameter of 8 to 10 nm. A heterozygous E148Q mutation in the MEFV gene was identified. Conventional disease-modifying anti-rheumatic drugs and etanercept had been used to treat the SJIA, but the disease could not be controlled. Therefore, we decided to start tocilizumab to control the disease activity. However, the patient was unable to receive a standard dose of tocilizumab in the early period of treatment because of socioeconomic limitations. Her disease course was still active, and proteinuria was found. Therefore, tocilizumab was increased to a dose of 8 mg/kg every 2 weeks (standard dose of SJIA), and the patient exhibited a clinical response within 3 months.", + "summary_subclaims": [ + "The patient was a 19-year-old female.", + "The patient had difficult-to-control SJIA.", + "The patient developed progressive proteinuria.", + "There were no clinical signs or symptoms of edema.", + "Renal amyloidosis was diagnosed by renal pathologic examination.", + "Eosinophilic amorphous material was deposited in the interlobular arteries.", + "Eosinophilic amorphous material was deposited in the arterioles.", + "Eosinophilic amorphous material was deposited in the interstitium.", + "Electron microscopy showed fibrillary material deposits.", + "The fibrillary material deposits had a diameter of 8 to 10 nm.", + "A heterozygous E148Q mutation in the MEFV gene was identified.", + "Conventional disease-modifying anti-rheumatic drugs had been used to treat the SJIA.", + "Etanercept had been used to treat the SJIA.", + "The disease could not be controlled.", + "Tocilizumab was started to control the disease activity.", + "The patient was unable to receive a standard dose of tocilizumab in the early period of treatment.", + "The patient had socioeconomic limitations.", + "The disease course was still active.", + "Proteinuria was found.", + "Tocilizumab was increased to a dose of 8 mg/kg every 2 weeks.", + "The standard dose of tocilizumab for SJIA is 8 mg/kg every 2 weeks.", + "The patient exhibited a clinical response within 3 months." + ] + }, + { + "id": "multiclinsum_test_1177_en.txt", + "fulltext": "A 75-year-old woman was referred to our hospital with a gastroesophageal lesion. Upper gastrointestinal endoscopy revealed a raised lesion with ulceration on the posterior wall of the greater curvature of the cardia. The endoscopy also indicated tenderness in the lower esophagus and tumor invasion was suspected . Immunostaining of the tumor biopsy showed positive staining for Melan-A, human melanoma black-45 (HMB45), and S-100 protein (+), indicating malignant melanoma of the esophagogastric junction. Contrast-enhanced computed tomography (CT) of the abdomen showed a mildly stained lesion protruding into the cardiac part of stomach and enlarged perigastric lymph nodes (the right paracardial lymph node and lesser curvature lymph node were lumped together) . No obvious distant metastasis was observed. Serum analysis indicated that squamous cell carcinoma antigen, carcinoembryonic antigen, and carbohydrate antigen 19–9 were within normal limits. A positron emission tomography (PET)– CT scan showed a high degree of fluorodeoxyglucose accumulation (maximum standardized uptake value: early = 13.2, delayed = 19.2) in the upper stomach and enlarged lymph nodes. Based on these findings, we performed proximal gastrectomy, lower esophagus resection, and double-tract reconstruction. We also performed resection of the enlarged lymph node in the lesser curvature of stomach and no obvious distant metastasis in the abdominal cavity was found. Histological examination of the resected tissue indicated an elastic, soft tumor that was located in the esophagogastric junction (6 × 5 cm, Fig. a). Analysis of the tumor cell morphology demonstrated large, round tumor cells with nuclear atypia and high mitotic activity . Immunostaining was positive for Melan-A, HMB45, S-100 protein and SRY-box transcription factor 10 , and the patient was diagnosed with malignant melanoma of the esophagogastric junction with regional lymph node metastases. Postoperative recovery was good, and the patient was discharged on 22 days post-operation. Three months after the surgery, a follow-up CT showed subpleural masses in the lower lobe of the left lung, with bilateral pleural effusion . As previous analyses of the primary tumor had revealed BRAF-wild-type, the patient was prescribed with nivolumab, human immunoglobulin G4 monoclonal antibody, and inhibitor of programmed death-1 (PD-1) in accordance with melanoma treatment guidelines. Following three courses of nivolumab treatment, the patient presented with grade 3 renal dysfunction (Common Terminology Criteria for Adverse Events version 5.0) . The patient was prescribed steroid therapy for the immune-related adverse events that developed in response to the nivolumab treatment. Despite improved renal function, chemotherapy was discontinued at the patient's request. Five months after the presentation of renal dysfunction, a CT scan demonstrated an unstained nodule in the pancreas with dilation of the caudal pancreatic duct , although the size of the pleural metastasis was unchanged. Intensity-modulated radiotherapy (IMRT) was initiated for pancreatic metastasis treatment at 66 Gy. Six months after IMRT treatment, a CT scan revealed pancreatic nodule and pleural metastasis was shrunk. Eight months after the IMRT (13 months after nivolumab treatment completion), the pleural mass and pleural effusion had disappeared . PET–CT showed no obvious abnormal accumulation . We hypothesized that the abscopal effect was caused by the radiation therapy, and further enhanced by the nivolumab treatment, which had finished 5 months earlier; the timeline of these events is shown in Fig. . Twelve months after the onset of the abscopal effect, no additional lesions were observed and the patient had discontinued all treatment.", + "fulltext_subclaims": [ + "A 75-year-old woman was referred to our hospital with a gastroesophageal lesion.", + "Upper gastrointestinal endoscopy revealed a raised lesion with ulceration on the posterior wall of the greater curvature of the cardia.", + "The endoscopy also indicated tenderness in the lower esophagus.", + "Tumor invasion was suspected.", + "Immunostaining of the tumor biopsy showed positive staining for Melan-A.", + "Immunostaining of the tumor biopsy showed positive staining for human melanoma black-45 (HMB45).", + "Immunostaining of the tumor biopsy showed positive staining for S-100 protein (+).", + "Contrast-enhanced computed tomography (CT) of the abdomen showed a mildly stained lesion protruding into the cardiac part of the stomach.", + "Contrast-enhanced CT showed enlarged perigastric lymph nodes.", + "No obvious distant metastasis was observed.", + "Serum analysis indicated that squamous cell carcinoma antigen was within normal limits.", + "Serum analysis indicated that carcinoembryonic antigen was within normal limits.", + "Serum analysis indicated that carbohydrate antigen 19–9 was within normal limits.", + "A positron emission tomography (PET)–CT scan showed a high degree of fluorodeoxyglucose accumulation in the upper stomach.", + "The maximum standardized uptake value was early = 13.2.", + "The maximum standardized uptake value was delayed = 19.2.", + "Based on these findings, we performed proximal gastrectomy.", + "We performed lower esophagus resection.", + "We performed double-tract reconstruction.", + "We performed resection of the enlarged lymph node in the lesser curvature of the stomach.", + "Histological examination of the resected tissue indicated an elastic, soft tumor.", + "The tumor was located in the esophagogastric junction.", + "Analysis of the tumor cell morphology demonstrated large, round tumor cells with nuclear atypia.", + "Analysis of the tumor cell morphology demonstrated high mitotic activity.", + "Immunostaining was positive for Melan-A.", + "Immunostaining was positive for HMB45.", + "Immunostaining was positive for S-100 protein.", + "Immunostaining was positive for SRY-box transcription factor 10.", + "The patient was diagnosed with malignant melanoma of the esophagogastric junction.", + "The patient was diagnosed with regional lymph node metastases.", + "Postoperative recovery was good.", + "The patient was discharged on 22 days post-operation.", + "Three months after the surgery, a follow-up CT showed subpleural masses in the lower lobe of the left lung.", + "Three months after the surgery, a follow-up CT showed bilateral pleural effusion.", + "Previous analyses of the primary tumor had revealed BRAF-wild-type.", + "The patient was prescribed with nivolumab.", + "The patient was prescribed with human immunoglobulin G4 monoclonal antibody.", + "The patient was prescribed with inhibitor of programmed death-1 (PD-1).", + "Following three courses of nivolumab treatment, the patient presented with grade 3 renal dysfunction.", + "The patient was prescribed steroid therapy for the immune-related adverse events.", + "Chemotherapy was discontinued at the patient's request.", + "Five months after the presentation of renal dysfunction, a CT scan demonstrated an unstained nodule in the pancreas.", + "Five months after the presentation of renal dysfunction, a CT scan demonstrated dilation of the caudal pancreatic duct.", + "Intensity-modulated radiotherapy (IMRT) was initiated for pancreatic metastasis treatment at 66 Gy.", + "Six months after IMRT treatment, a CT scan revealed pancreatic nodule.", + "Six months after IMRT treatment, a CT scan revealed pleural metastasis was shrunk.", + "Eight months after the IMRT (13 months after nivolumab treatment completion), the pleural mass had disappeared.", + "Eight months after the IMRT (13 months after nivolumab treatment completion), the pleural effusion had disappeared.", + "PET–CT showed no obvious abnormal accumulation.", + "We hypothesized that the abscopal effect was caused by the radiation therapy.", + "We hypothesized that the abscopal effect was further enhanced by the nivolumab treatment.", + "Twelve months after the onset of the abscopal effect, no additional lesions were observed.", + "The patient had discontinued all treatment." + ], + "summary": "A 75-year-old woman was referred to our hospital with a gastroesophageal lesion. Upper gastrointestinal endoscopy revealed a raised lesion on the posterior wall of the greater curvature of the cardia and tenderness in the lower esophagus. Immunostaining of the tumor biopsy showed positive staining for Melan-A, human melanoma black-45 (HMB45), and S-100, indicating malignant melanoma of the esophagogastric junction. Contrast-enhanced computed tomography (CT) of the abdomen showed a mildly stained lesion protruding into the cardiac part of stomach and enlarged surrounding lymph nodes. The patient was diagnosed with malignant melanoma of the esophagogastric junction and proximal gastrectomy with lower esophagus resection was performed. Histological examination showed large, round tumor cells with nuclear atypia. Immunostaining was positive for Melan A, HMB45, S-100 protein, and SRY-box transcription factor 10, and the final diagnosis was malignant melanoma of the esophagogastric junction, with regional lymph node metastases. Three months after surgery, follow-up CT indicated left pleural metastasis; therefore, the patient was administered nivolumab, an immune checkpoint inhibitor (ICI). Following three courses of nivolumab, the patient exhibited grade 3 renal dysfunction (Common Terminology Criteria for Adverse Events version 5.0). After that, we have not administered nivolumab treatment. Five months after the development of renal dysfunction, a CT scan demonstrated an unstained nodule within the pancreatic, and the patient was diagnosed with pancreatic metastasis; intensity-modulated radiotherapy was performed. Six months later, CT revealed pancreatic nodule and pleural metastasis was shrunk; after an additional 2 months, pleural metastasis and effusion had disappeared. The patient is alive with no additional lesions.", + "summary_subclaims": [ + "The patient is a 75-year-old woman.", + "The patient was referred to the hospital with a gastroesophageal lesion.", + "Upper gastrointestinal endoscopy revealed a raised lesion on the posterior wall of the greater curvature of the cardia.", + "Immunostaining of the tumor biopsy showed positive staining for Melan-A.", + "Immunostaining of the tumor biopsy showed positive staining for human melanoma black-45 (HMB45).", + "Immunostaining of the tumor biopsy showed positive staining for S-100.", + "Contrast-enhanced computed tomography (CT) of the abdomen showed a mildly stained lesion protruding into the cardiac part of the stomach.", + "The patient was diagnosed with malignant melanoma of the esophagogastric junction.", + "Proximal gastrectomy with lower esophagus resection was performed.", + "Histological examination showed large, round tumor cells with nuclear atypia.", + "Immunostaining was positive for Melan A.", + "Immunostaining was positive for HMB45.", + "Immunostaining was positive for S-100 protein.", + "The final diagnosis was malignant melanoma of the esophagogastric junction.", + "Three months after surgery, follow-up CT indicated left pleural metastasis.", + "The patient was administered nivolumab, an immune checkpoint inhibitor (ICI).", + "Following three courses of nivolumab, the patient exhibited grade 3 renal dysfunction.", + "After the development of renal dysfunction, nivolumab treatment was not administered.", + "Five months after the development of renal dysfunction, a CT scan demonstrated an unstained nodule within the pancreatic.", + "The patient was diagnosed with pancreatic metastasis.", + "Intensity-modulated radiotherapy was performed.", + "Six months later, CT revealed pancreatic nodule and pleural metastasis was shrunk.", + "After an additional 2 months, pleural metastasis and effusion had disappeared.", + "The patient is alive with no additional lesions." + ] + }, + { + "id": "multiclinsum_test_1371_en.txt", + "fulltext": "A 4-year-old male was admitted to the ED of our hospital with generalized urticaria. He had been fishing with his father and, 10 min after lying down on grass, he experienced generalized itchy urticaria and angioedema. Thirty minutes later, on examination in the Emergency Department, urticaria was observed over the entire body and angioedema in his hands.\nBenadryl and methylprednisolone were administered. Four hours after treatment, symptoms had stopped, and urticaria and angioedema had disappeared completely.\nTwo weeks later, he visited a farm. Fifteen minutes after lying down on grass he experienced itching sensations in his hands, arms and trunk, along with generalized erythema. He also complained of congestion/itching in his nose, itchy eyes, and crying. His mother stated that he had slight dyspnea with cough and dizziness. She gave him Benadryl and betamethasone via the oral route based on advice proffered in a previous admission to the ED (which improved the most severe symptoms within 1 h). He was admitted to the ED after 2 h with only erythema, and he received antihistamines for an additional 5 days. The patient had no history of atopy.\nBy anamnesis, an etiology of insect bites, or intake of food or drugs before these two episodes were excluded. Total Immunoglobulin-E was 123 IU/mL, the blood count and complement (CH50, C3, C4, C1 inhibitor) were normal. Parasitology studies were negative. His mother and maternal grandmother reported a history of allergic rhinitis.\nSkin-prick tests (SPTs; Dermaprick®; Alergo Pharma, Buenos Aires, Argentina) were positive to Cynodon dactylis, Phalaris arundinacea and Festuca elatior. Surprisingly these allergens were significantly positive (largest diameter (in mm): 8, 12 and 23, respectively), compared with that of the negative control (1 mm) . These pollen allergens are used by our research team to ascertain the prevalence of skin sensitivity .\nSPTs were negative for foods (milk, egg, cocoa, citrus fruits, fish, tomatoes, peanuts, wheat, bananas, strawberries) and airborne allergens (Dermatophagoides farinae, D. pteronyssinus, cat dander, dog dander, Alternaria spp., Aspergillus spp., Mucor spp., Cladosporium spp., Penicillium spp., Rhizopus spp., other grasses, weeds, tree pollens).", + "fulltext_subclaims": [ + "A 4-year-old male was admitted to the ED of our hospital with generalized urticaria.", + "He had been fishing with his father.", + "Ten minutes after lying down on grass, he experienced generalized itchy urticaria and angioedema.", + "Thirty minutes later, on examination in the Emergency Department, urticaria was observed over the entire body.", + "Angioedema was observed in his hands.", + "Benadryl and methylprednisolone were administered.", + "Four hours after treatment, symptoms had stopped.", + "Urticaria and angioedema had disappeared completely.", + "Two weeks later, he visited a farm.", + "Fifteen minutes after lying down on grass, he experienced itching sensations in his hands, arms and trunk.", + "Generalized erythema was observed.", + "He also complained of congestion/itching in his nose.", + "He also complained of itchy eyes and crying.", + "His mother stated that he had slight dyspnea with cough and dizziness.", + "She gave him Benadryl and betamethasone via the oral route.", + "He was admitted to the ED after 2 h with only erythema.", + "He received antihistamines for an additional 5 days.", + "The patient had no history of atopy.", + "An etiology of insect bites was excluded.", + "Intake of food or drugs before these two episodes was excluded.", + "Total Immunoglobulin-E was 123 IU/mL.", + "The blood count and complement (CH50, C3, C4, C1 inhibitor) were normal.", + "Parasitology studies were negative.", + "His mother and maternal grandmother reported a history of allergic rhinitis.", + "Skin-prick tests (SPTs; Dermaprick®; Alergo Pharma, Buenos Aires, Argentina) were positive to Cynodon dactylis.", + "SPTs were positive to Phalaris arundinacea.", + "SPTs were positive to Festuca elatior.", + "The largest diameter of the SPT to Festuca elatior was 23 mm.", + "These pollen allergens are used by our research team to ascertain the prevalence of skin sensitivity.", + "SPTs were negative for foods (milk, egg, cocoa, citrus fruits, fish, tomatoes, peanuts, wheat, bananas, strawberries).", + "SPTs were negative for airborne allergens (Dermatophagoides farinae, D. pteronyssinus, cat dander, dog dander, Alternaria spp., Aspergillus spp., Mucor spp., Cladosporium spp., Penicillium spp., Rhizopus spp., other grasses, weeds, tree pollens)." + ], + "summary": "We described a 4-year-old male child with anaphylaxis exposed to grasses. Patient also suffered mild neurologic/respiratory symptoms but it is unlikely that he had anaphylaxis. Skin-prick tests were positive to Cynodon dactylis, Phalaris arundinacea and Festuca elatior. Little is known about the importance of pollens as a cause of urticaria in young children.", + "summary_subclaims": [ + "We described a 4-year-old male child with anaphylaxis exposed to grasses.", + "Patient also suffered mild neurologic/respiratory symptoms.", + "It is unlikely that he had anaphylaxis.", + "Skin-prick tests were positive to Cynodon dactylis.", + "Skin-prick tests were positive to Phalaris arundinacea.", + "Skin-prick tests were positive to Festuca elatior.", + "Little is known about the importance of pollens as a cause of urticaria in young children." + ] + }, + { + "id": "multiclinsum_test_2343_en.txt", + "fulltext": "An 8-year-old girl presented in August 2015 to the Royal Belfast Hospital for Sick Children’s Accident and Emergency department with headache for 2 months. These had been increasing in intensity and frequency for the preceding 3 weeks requiring her to take paracetamol on a daily basis. At times the headache was associated with redness and watering of her left eye. She attended her optician due to the headaches who noted an abnormal appearance of her left fundus. She denied any visual loss or any other visual symptoms. There were no previous eye problems known.\nSystemic enquiry revealed she had occasional nosebleeds. There was no foreign travel except for a family holiday in Spain twelve months previously. As her grandfather was from South Africa, she had received the Bacillus Calmette-Guérin (BCG) vaccine. Her family had a pet dog that lives outside. There were no cats and she did not live on a farm. There was no history of tick bites or cat scratches. She reported no recent viral illness or vaccinations and no recent pyrexia, fatigue, cough or sore throat. She had no known underlying medical conditions. She was not on any medications except for paracetamol as required for her headaches.\nAged 7, she had previously been admitted for investigation of pyrexia and left knee swelling. At that time, mum described her as having a bruise-like rash around the affected left knee. She was extensively investigated as a Magnetic Resonance Imaging (MRI) scan showed abnormal changes in and around both knees. Bilateral bone marrow trephine of each posterior iliac crest and bone morrow aspirate and biopsy of the affected distal femur were all negative. Haematological malignancy was excluded. Of note, at that time her C-Reactive Protein (CRP) was 69 mg/L and Erythrocyte Sedimentation Rate (ESR) was 110 mm/hr. but otherwise blood testing did not identify any specific underlying diagnosis for her peculiar presentation.\nThe examination findings at presentation are shown in Table and Fig. .\nShe was admitted with findings of left posterior uveitis and mild vitritis for further investigation. A differential diagnosis of unilateral chorioretinitis included infectious chorioretinitis such as toxoplasma, toxocara, tuberculosis, syphilis, borriella burgdorferi (B.burgdorferi) and post-streptococcal syndrome and inflammatory chorioretinitis such as sarcoidosis, multifocal choroiditis and other white dot syndromes. An infiltrative cause was also considered.\nExtensive investigations, as presented in Table , failed to identify a specific cause for her unilateral chorioretinitis.\nOver the following 4 months, without treatment, her vision increased in the left eye to 6/12 unaided and the fundal appearance improved showing reduced sub-retinal infiltration; however, a focal circular area of chorioretinitis developed along the superotemporal arcade . One month later, the circular area of chorioretinitis had faded but a new active area of chorioretinitis was noted superior to the disc. Within this area, an elongated, white, glistening nematode was identified with an estimated size of 1500 μm when compared with the optic disc diameter . Ocular coherence tomography horizontally through this new area of active chorioretinitis indicated a nematode with tapered end curling upwards from subretinal space into deep retinal layers . This led to a working diagnosis of diffuse unilateral subacute neuroretinitis (DUSN).\nFollowing diagnosis of DUSN, diode laser was performed under general anaesthetic to the superior area of active chorioretinitis and presumed nematode. The patient was also commenced on oral albendazole 200 mg twice daily for 1 month and a reducing course of oral prednisolone starting at 25 mg daily and tapered over 30 days. After another month, her visual acuity had improved further to 6/9 and the treated area of chorioretinitis superior to the optic disc had disappeared. However, new areas of chorioretinitis had appeared temporal to the superotemporal arcade and in the inferonasal fundus . A further course of oral albendazole 200 mg twice daily and oral prednisolone 7.5 mg was commenced and planned for 30 days but was discontinued by the patient after 2 weeks. After a further 2 months, the fundal appearance had changed once again and new areas of chorioretinitis had appeared in the superotemporal retina with resolution of the areas inferonasally and temporal to the superotemporal arcade . Further laser was administered to the new superior lesion where a nematode was suspected. Despite additional anti-helminthic treatment with ivermectin, recurrence of active chorioretinitis lesions continued and electrophysiology testing indicated significant left retinal dysfunction.\nA specialist uveitis opinion was sought from a tertiary centre in London that concurred with the diagnosis of DUSN; but it was thought that a secondary immune-mediated inflammatory response might be contributing to the clinical picture. Another tapering course of oral prednisolone along with mycophenolate mofetil was trialled without success. At last review, 19 months from initial presentation, the fundal appearance continued to change and a new area of focal chorioretinitis had appeared at the temporal macula .", + "fulltext_subclaims": [ + "An 8-year-old girl presented in August 2015 to the Royal Belfast Hospital for Sick Children’s Accident and Emergency department with headache for 2 months.", + "The headaches had been increasing in intensity and frequency for the preceding 3 weeks.", + "She required paracetamol on a daily basis.", + "At times the headache was associated with redness and watering of her left eye.", + "She attended her optician due to the headaches who noted an abnormal appearance of her left fundus.", + "She denied any visual loss or any other visual symptoms.", + "There were no previous eye problems known.", + "Systemic enquiry revealed she had occasional nosebleeds.", + "There was no foreign travel except for a family holiday in Spain twelve months previously.", + "She had received the Bacillus Calmette-Guérin (BCG) vaccine.", + "Her family had a pet dog that lives outside.", + "There were no cats and she did not live on a farm.", + "There was no history of tick bites or cat scratches.", + "She reported no recent viral illness or vaccinations.", + "She had no recent pyrexia, fatigue, cough or sore throat.", + "She had no known underlying medical conditions.", + "She was not on any medications except for paracetamol as required for her headaches.", + "Aged 7, she had previously been admitted for investigation of pyrexia and left knee swelling.", + "At that time, mum described her as having a bruise-like rash around the affected left knee.", + "An MRI scan showed abnormal changes in and around both knees.", + "Bilateral bone marrow trephine of each posterior iliac crest and bone marrow aspirate and biopsy of the affected distal femur were all negative.", + "Haematological malignancy was excluded.", + "At that time her C-Reactive Protein (CRP) was 69 mg/L.", + "Her Erythrocyte Sedimentation Rate (ESR) was 110 mm/hr.", + "Blood testing did not identify any specific underlying diagnosis for her peculiar presentation.", + "She was admitted with findings of left posterior uveitis and mild vitritis for further investigation.", + "A differential diagnosis of unilateral chorioretinitis included infectious chorioretinitis such as toxoplasma, toxocara, tuberculosis, syphilis, borriella burgdorferi (B.burgdorferi) and post-streptococcal syndrome.", + "A differential diagnosis of unilateral chorioretinitis included inflammatory chorioretinitis such as sarcoidosis, multifocal choroiditis and other white dot syndromes.", + "An infiltrative cause was also considered.", + "Extensive investigations failed to identify a specific cause for her unilateral chorioretinitis.", + "Over the following 4 months, without treatment, her vision increased in the left eye to 6/12 unaided.", + "The fundal appearance improved showing reduced sub-retinal infiltration.", + "A focal circular area of chorioretinitis developed along the superotemporal arcade.", + "One month later, the circular area of chorioretinitis had faded but a new active area of chorioretinitis was noted superior to the disc.", + "An elongated, white, glistening nematode was identified with an estimated size of 1500 μm when compared with the optic disc diameter.", + "Ocular coherence tomography horizontally through this new area of active chorioretinitis indicated a nematode with tapered end curling upwards from subretinal space into deep retinal layers.", + "This led to a working diagnosis of diffuse unilateral subacute neuroretinitis (DUSN).", + "Following diagnosis of DUSN, diode laser was performed under general anaesthetic to the superior area of active chorioretinitis and presumed nematode.", + "The patient was also commenced on oral albendazole 200 mg twice daily for 1 month.", + "A reducing course of oral prednisolone starting at 25 mg daily and tapered over 30 days was commenced.", + "After another month, her visual acuity had improved further to 6/9.", + "The treated area of chorioretinitis superior to the optic disc had disappeared.", + "New areas of chorioretinitis had appeared temporal to the superotemporal arcade and in the inferonasal fundus.", + "A further course of oral albendazole 200 mg twice daily and oral prednisolone 7.5 mg was commenced and planned for 30 days.", + "The course was discontinued by the patient after 2 weeks.", + "After a further 2 months, the fundal appearance had changed once again.", + "New areas of chorioretinitis had appeared in the superotemporal retina with resolution of the areas inferonasally and temporal to the superotemporal arcade.", + "Further laser was administered to the new superior lesion where a nematode was suspected.", + "Despite additional anti-helminthic treatment with ivermectin, recurrence of active chorioretinitis lesions continued.", + "Electrophysiology testing indicated significant left retinal dysfunction.", + "A specialist uveitis opinion was sought from a tertiary centre in London that concurred with the diagnosis of DUSN.", + "It was thought that a secondary immune-mediated inflammatory response might be contributing to the clinical picture.", + "Another tapering course of oral prednisolone along with mycophenolate mofetil was trialled without success.", + "At last review, 19 months from initial presentation, the fundal appearance continued to change.", + "A new area of focal chorioretinitis had appeared at the temporal macula." + ], + "summary": "An 8-year-old girl presented with a 2-month history of headaches. On occasions the headaches were associated with redness and watering of her left eye. She denied any visual loss or visual symptoms. Her visual acuity was reduced to 6/30 in her left eye. Fundal examination revealed a unilateral chorioretinitis. Investigation did not reveal a specific cause for the chorioretinitis. Over 15 months her visual acuity improved to 6/9 but the fundal appearance changed and a diagnosis of DUSN was made. She was treated with focal laser, systemic anti-helminthic and immunosuppressive treatments but continued to develop new, active areas of chorioretinitis, raising the possibility of multiple worms in the sub-retinal space. There is also a concern as to other central nervous system (CNS) involvement given her significant and ongoing headaches.", + "summary_subclaims": [ + "The patient is an 8-year-old girl.", + "She had a 2-month history of headaches.", + "The headaches were occasionally associated with redness and watering of her left eye.", + "She denied any visual loss or visual symptoms.", + "Her visual acuity was reduced to 6/30 in her left eye.", + "Fundal examination revealed a unilateral chorioretinitis.", + "Investigation did not reveal a specific cause for the chorioretinitis.", + "Over 15 months her visual acuity improved to 6/9.", + "The fundal appearance changed and a diagnosis of DUSN was made.", + "She was treated with focal laser, systemic anti-helminthic, and immunosuppressive treatments.", + "She continued to develop new, active areas of chorioretinitis.", + "This raised the possibility of multiple worms in the sub-retinal space.", + "There is also a concern as to other central nervous system (CNS) involvement given her significant and ongoing headaches." + ] + }, + { + "id": "multiclinsum_test_3378_en.txt", + "fulltext": "The patient is a 46-year-old male with a three months’ history of progressive dyspnea on exertion. His past medical history was significant testicular cancer involving the right testes 32 years prior with pulmonary and widespread lymph nodal metastasis. He was treated at that time with orchiectomy, and chemotherapy along with radiation to the brachial plexus for distant metastasis. Eight years later, the patient was found to have a pulmonary nodule on chest x-ray that was treated surgically and was a teratoma. Since then the patient had remained asymptomatic.\n\nAs a part of a dyspnea workup, the patient underwent a transthoracic echocardiogram (TTE) that showed two large, well circumscribed, partially mobile right ventricular masses. One was in the right ventricular outflow tract (RVOT) measuring 2.8×2.0 cm) and the other was toward the RV apical free wall (3.3×2.9 cm). The RV and left ventricle (LV) systolic function was normal though the RV was mildly dilated. There was color flow turbulence across the RVOT indicating some obstruction to flow, though velocity was not elevated. The patient was subsequently admitted to the hospital with Cardiothoracic Surgery and Oncology consults for further workup of his RV masses.\n\nCardiac magnetic resonance imaging (MRI) also showed these two intra-cardiac masses in the RV. One was located in the RVOT and the other in the diaphragmatic wall of the RV. Dynamic perfusion MRI demonstrated central delayed hyper-enhancement suggesting necrosis. These findings were thought to be suggestive of tumor. RV systolic function was low normal. Chest computerized tomography (CT) re-demonstrated the RV masses but also showed scattered areas of nodularity in the peripheral pulmonary arteries with areas of peripheral wedge-shaped consolidation and ground glass opacity likely related to tumor emboli and associated pulmonary infarcts. Supraclavicular and gastro-hepatic adenopathy was noted that was concerning for metastatic disease. These findings were new compared to prior CT from two years ago. Testicular ultrasound was negative for recurrence of cancer in the solitary remaining testicle.\n\nLaboratory data demonstrated elevated brain natriuretic peptide at 466 pg/mL (normal 0–100 pg/mL), minimal elevations in α-fetoprotein (AFP) to 32 ng/mL (normal 0–15 ng/mL), and LDH to 300 U/L (normal 100–210 U/L). B-HCG was negative. Mild thrombocytopenia was also noted with a platelet count of 132,000 U/mL. Troponin was negative at <0.02 ng/mL (normal 0.00–0.07 ng/mL).\n\nGiven concerns for RVOT obstruction, early RV failure and multiple tumor emboli to the lungs, patient was taken to the operating room by Cardiothoracic Surgery team for resection of the masses. On intra-operative gross visualization, the first mass was noted to be a pedunculated mass with a thin stalk while the second mass was a sessile mass imbedded in the wall of the ventricle. The pedunculated mass was easily resected in total. The sessile mass was debulked so as to not compromise the ventricular wall or damage the tricuspid valve.\n\nThe specimens were sent to pathology. Both tumors were positive for glypican 3, pancytokeratin, antibody to CDX2, and AFP. They were negative for OCT4, TTF-1, PAX-8, vimentin, WT-1, and podoplanin. Ki-67 showed a high proliferative index. Several histological features of these masses were consistent with yolk sac carcinoma with endodermal differentiation. The first finding consistent with yolk sac carcinoma was presence of periodic acid Schiff positive hyaline bodies known as Schiller-Duval bodies. Second was the presence of mixed mesenchymal and epithelial cells, tubular and papillary structures and possibly an eosinophilic basement membrane known as Reichert’s membrane. Lastly, immunochemical staining for AFP was used to confirm the diagnosis.\n\nPost procedure the patient continued to deteriorate clinically with worsening right-sided heart failure, requiring multiple vasopressor medications. Initial plan was for PET/CT of the abdomen/pelvis for identification of primary tumor and staging followed by chemotherapy. However, the patient was never hemodynamically stable to undergo further testing and unfortunately passed away 14 days after the surgery. The family opted to forgo an autopsy so complete staging of the cancer was left incomplete.", + "fulltext_subclaims": [ + "The patient is a 46-year-old male with a three months’ history of progressive dyspnea on exertion.", + "His past medical history was significant for testicular cancer involving the right testes 32 years prior with pulmonary and widespread lymph nodal metastasis.", + "He was treated at that time with orchiectomy, and chemotherapy along with radiation to the brachial plexus for distant metastasis.", + "Eight years later, the patient was found to have a pulmonary nodule on chest x-ray that was treated surgically and was a teratoma.", + "Since then the patient had remained asymptomatic.", + "The patient underwent a transthoracic echocardiogram (TTE) that showed two large, well circumscribed, partially mobile right ventricular masses.", + "One was in the right ventricular outflow tract (RVOT) measuring 2.8×2.0 cm.", + "The other was toward the RV apical free wall (3.3×2.9 cm).", + "The RV and left ventricle (LV) systolic function was normal though the RV was mildly dilated.", + "There was color flow turbulence across the RVOT indicating some obstruction to flow, though velocity was not elevated.", + "The patient was subsequently admitted to the hospital with Cardiothoracic Surgery and Oncology consults for further workup of his RV masses.", + "Cardiac magnetic resonance imaging (MRI) also showed these two intra-cardiac masses in the RV.", + "One was located in the RVOT and the other in the diaphragmatic wall of the RV.", + "Dynamic perfusion MRI demonstrated central delayed hyper-enhancement suggesting necrosis.", + "These findings were thought to be suggestive of tumor.", + "RV systolic function was low normal.", + "Chest computerized tomography (CT) re-demonstrated the RV masses but also showed scattered areas of nodularity in the peripheral pulmonary arteries with areas of peripheral wedge-shaped consolidation and ground glass opacity likely related to tumor emboli and associated pulmonary infarcts.", + "Supraclavicular and gastro-hepatic adenopathy was noted that was concerning for metastatic disease.", + "These findings were new compared to prior CT from two years ago.", + "Testicular ultrasound was negative for recurrence of cancer in the solitary remaining testicle.", + "Laboratory data demonstrated elevated brain natriuretic peptide at 466 pg/mL.", + "α-fetoprotein (AFP) was 32 ng/mL.", + "LDH was 300 U/L.", + "B-HCG was negative.", + "Mild thrombocytopenia was also noted with a platelet count of 132,000 U/mL.", + "Troponin was negative at <0.02 ng/mL.", + "Given concerns for RVOT obstruction, early RV failure and multiple tumor emboli to the lungs, patient was taken to the operating room by Cardiothoracic Surgery team for resection of the masses.", + "On intra-operative gross visualization, the first mass was noted to be a pedunculated mass with a thin stalk while the second mass was a sessile mass imbedded in the wall of the ventricle.", + "The pedunculated mass was easily resected in total.", + "The sessile mass was debulked so as to not compromise the ventricular wall or damage the tricuspid valve.", + "Both tumors were positive for glypican 3, pancytokeratin, antibody to CDX2, and AFP.", + "They were negative for OCT4, TTF-1, PAX-8, vimentin, WT-1, and podoplanin.", + "Ki-67 showed a high proliferative index.", + "Several histological features of these masses were consistent with yolk sac carcinoma with endodermal differentiation.", + "The first finding consistent with yolk sac carcinoma was presence of periodic acid Schiff positive hyaline bodies known as Schiller-Duval bodies.", + "Second was the presence of mixed mesenchymal and epithelial cells, tubular and papillary structures and possibly an eosinophilic basement membrane known as Reichert’s membrane.", + "Lastly, immunochemical staining for AFP was used to confirm the diagnosis.", + "Post procedure the patient continued to deteriorate clinically with worsening right-sided heart failure, requiring multiple vasopressor medications.", + "Initial plan was for PET/CT of the abdomen/pelvis for identification of primary tumor and staging followed by chemotherapy.", + "However, the patient was never hemodynamically stable to undergo further testing and unfortunately passed away 14 days after the surgery.", + "The family opted to forgo an autopsy so complete staging of the cancer was left incomplete." + ], + "summary": "Patient: Male, 46\n\nFinal Diagnosis: Yolk Sac tumor\n\nSymptoms: Shortness of breath\n\nMedication: —\n\nClinical Procedure: Cardiac MRI • tumor resection\n\nThe patient is a 46-year-old male with a history of testicular cancer that presented with dyspnea on exertion. He was found to have two large right sided intracardiac masses on echocardiography. Cardiac magnetic resonance imaging (MRI) was obtained to further investigate these masses. Right ventricular function was decreased and concern for right ventricular outflow tract (RVOT) obstruction was present. The patient was taken to the operating room (OR) for resection of the cardiac masses. Pathology revealed the masses to be yolk sac tumors. Despite urgent resection of the tumors, the patient deteriorated clinically, ultimately succumbing to heart failure.", + "summary_subclaims": [ + "The patient is a 46-year-old male.", + "The patient has a history of testicular cancer.", + "The patient presented with dyspnea on exertion.", + "Echocardiography showed two large right-sided intracardiac masses.", + "Cardiac MRI was obtained.", + "Right ventricular function was decreased.", + "Concern for right ventricular outflow tract obstruction was present.", + "The patient underwent resection of the cardiac masses.", + "Pathology revealed the masses to be yolk sac tumors.", + "The patient ultimately succumbed to heart failure." + ] + }, + { + "id": "multiclinsum_test_2961_en.txt", + "fulltext": "A 12-year-old female patient presented to us with the complaint of pain, swelling and purulent discharge from her left heel. She had a history of similar episodes in the near past, for which she underwent incision and drainage elsewhere. She had a swollen red heel with a linear scar on its lateral aspect with pus discharge from the site on examination. Her blood parameters like WBC, ESR and CRP were elevated. A radiograph of the region revealed calcaneal bone destruction and surrounding osteopenia . Sinogram tracks the sinus, which was arising from the body of the calcaneum. Magnetic resonance imaging was suggestive of osteomyelitis of the body of calcaneum . A culture study of the swab, taken from a deeper aspect of the wound, showed the growth of methicillin-resistant S. aureus bacteria. After diagnosing chronic osteomyelitis of calcaneum was confirmed, the patient was planned for a single-stage operative procedure under systemic antibiotic coverage.\nThe calcaneum was approached laterally with an L shaped incision. Thorough debridement was done; the infected bone was curetted out and sent for culture examination . We use 10cc of calcium sulphate (STIMULAN®, Biocomposites) as bone defect filler, and for local antibiotic delivery, stimulan® paste was mixed with 1g of vancomycin moulded into multiple pellets through a sterile cast. The bone defect was filled with these pellets , and the wound was primarily closed, and the limb was supported by below-knee posterior POP (Plaster of Paris) slab. Postoperatively, on day 2, the wound was okay, and there was no discharge, and the radiograph showed the excellent placement of stimulan® . Intravenous antibiotics were continued for 1 week postoperatively. The patient was discharged with slab support and on oral antibiotics and calcium supplements. Post-operatively, after 2 weeks, the wound was healthy, and all sutures were removed.\nThe patient was followed up after 1 month, 3 months and 6 months. After 1-month oral antibiotics were discontinued, and she was allowed to do walker assisted partial weight-bearing. Clinically and through radiographs , she showed no signs of recurrence of infection and was utterly allowed to weight bear after 3rd month follow-up. Further, follow-up visits were uneventful.", + "fulltext_subclaims": [ + "The patient is a 12-year-old female.", + "She presented with pain, swelling, and purulent discharge from her left heel.", + "She had a history of similar episodes in the near past.", + "She underwent incision and drainage elsewhere.", + "On examination, she had a swollen red heel with a linear scar on its lateral aspect.", + "Pus discharge was observed from the scar site.", + "Her WBC, ESR, and CRP were elevated.", + "A radiograph revealed calcaneal bone destruction and surrounding osteopenia.", + "Sinogram tracks the sinus arising from the body of the calcaneum.", + "Magnetic resonance imaging was suggestive of osteomyelitis of the body of calcaneum.", + "A culture study of the swab showed the growth of methicillin-resistant S. aureus bacteria.", + "Chronic osteomyelitis of calcaneum was confirmed.", + "The patient was planned for a single-stage operative procedure under systemic antibiotic coverage.", + "The calcaneum was approached laterally with an L-shaped incision.", + "Thorough debridement was done.", + "The infected bone was curetted out and sent for culture examination.", + "10cc of calcium sulphate (STIMULAN®, Biocomposites) was used as bone defect filler.", + "Stimulan® paste was mixed with 1g of vancomycin.", + "The paste was moulded into multiple pellets through a sterile cast.", + "The bone defect was filled with these pellets.", + "The wound was primarily closed.", + "The limb was supported by a below-knee posterior POP slab.", + "Postoperatively, on day 2, the wound was okay with no discharge.", + "The radiograph showed excellent placement of stimulan®.", + "Intravenous antibiotics were continued for 1 week postoperatively.", + "The patient was discharged with slab support.", + "She was on oral antibiotics and calcium supplements.", + "After 2 weeks, the wound was healthy, and all sutures were removed.", + "The patient was followed up after 1 month, 3 months, and 6 months.", + "After 1 month, oral antibiotics were discontinued.", + "She was allowed walker-assisted partial weight-bearing.", + "Clinically and through radiographs, she showed no signs of recurrence of infection.", + "She was allowed to weight bear after the 3rd month follow-up.", + "Further follow-up visits were uneventful." + ], + "summary": "A female patient presented with pain, swelling and purulent discharge from the left heel. Culture studies and magnetic resonance imaging findings were suggestive of osteomyelitis of the calcaneum. The patient was planned for definitive treatment, and remission was achieved with systemic antibiotics, debridement, curettage, and filling dead space with antibiotic mixed calcium sulphate pellets.", + "summary_subclaims": [ + "The patient was a female.", + "The patient had pain from the left heel.", + "The patient had swelling from the left heel.", + "The patient had purulent discharge from the left heel.", + "Culture studies and magnetic resonance imaging findings were suggestive of osteomyelitis of the calcaneum.", + "The patient was planned for definitive treatment.", + "Remission was achieved with systemic antibiotics.", + "Remission was achieved with debridement.", + "Remission was achieved with curettage.", + "Remission was achieved with filling dead space with antibiotic mixed calcium sulphate pellets." + ] + }, + { + "id": "multiclinsum_test_191_en.txt", + "fulltext": "A 33-year-old male smoker with no prior medical history came to the emergency department with sudden onset dyspnea and hemoptysis associated with lower limb edema. The physical examination found: heart rate 125 bpm, regular sinus rhythm with no added sounds, blood pressure 240/130 mmHg, polypnea at 45 breaths per minute, normal oxygen saturation, limited bilateral air entry with crepitation, lower limbs pitting edema, hepatojugular reflex, no evidence of deep vein thrombosis, normal abdominal examination. Biological markers were hemoglobin 15 g/dl, white blood cells 16 G/l, CRP 87 mg/L, ProBNP 3612 pg/mL, stable troponin at 76 ng/ml, sodium 133 mmol/L, potassium 4.7 mmol/L, creatinine 100 μmol/L.", + "fulltext_subclaims": [ + "The patient is a 33-year-old male.", + "The patient is a smoker.", + "The patient has no prior medical history.", + "The patient had sudden onset dyspnea.", + "The patient had hemoptysis.", + "The patient had lower limb edema.", + "The heart rate was 125 bpm.", + "The rhythm was regular sinus.", + "The blood pressure was 240/130 mmHg.", + "The respiratory rate was 45 breaths per minute.", + "Oxygen saturation was normal.", + "There was limited bilateral air entry.", + "There was crepitation.", + "There was pitting edema in the lower limbs.", + "There was a positive hepatojugular reflex.", + "There was no evidence of deep vein thrombosis.", + "The hemoglobin was 15 g/dl.", + "The white blood cells were 16 G/l.", + "The CRP was 87 mg/L.", + "The ProBNP was 3612 pg/mL.", + "The troponin was stable at 76 ng/ml.", + "The sodium was 133 mmol/L.", + "The potassium was 4.7 mmol/L.", + "The creatinine was 100 μmol/L." + ], + "summary": "We report an unusual association of pulmonary embolism and testicular germ cell tumor complicating severe left heart failure and full recovery at three months follow up in a 33-year-old patient with no prior medical history. The diagnosis was made after comprehensive history taking and physical examination with the help of different imaging modalities. Full recovery was achieved after optimal medical therapy.", + "summary_subclaims": [ + "We report an unusual association of pulmonary embolism and testicular germ cell tumor.", + "The association complicates severe left heart failure.", + "The patient is a 33-year-old with no prior medical history.", + "The diagnosis was made after comprehensive history taking and physical examination.", + "Different imaging modalities were used in the diagnosis.", + "Full recovery was achieved after optimal medical therapy." + ] + }, + { + "id": "multiclinsum_test_2811_en.txt", + "fulltext": "An 81-year-old female patient presented to our emergency department with acute onset of hematemesis and melena. On admission, the patient appeared to have a poor general health condition and was hemodynamically compromised. Her initial laboratory exams revealed a hemoglobin concentration of 7.7 mg/dl without leukocytosis or C-reactive protein (CRP) elevation. The patient had a history of a 6.5 cm gastrointestinal stromal tumor (GIST) of the cardia, for which she initially received downsizing treatment with imatinib 400 mg/d, followed by surgical resection of the gastroesophageal junction and reconstruction with a jejunal interposition (Merendino procedure) 4 years earlier . Histopathological studies of the tumor revealed a T3-tumor with a positive c-Kit mutation in exon-11 and a Ki-67 proliferation rate of 15%. The risk for disease progression based on Miettinen's criteria was determined as high (size > 5 cm; mitosis rate > 5/HPF), and the patient was subsequently placed on 1st line adjuvant therapy with imatinib 400 mg/d . After two years on 1st line treatment, the patient developed hepatic and peritoneal metastasis and was placed on sunitinib as 2nd line therapy for metastatic GIST. Treatment with a proton pump inhibitor (PPI) was suspended for an unknown reason two years prior to presentation.\nThe patient was immediately transferred to our intensive care unit, where she was intubated and received two units of packed red blood cells (pRBCs). An emergency gastroscopy was carried out, which revealed active bleeding from a vessel stump in the jejunal interposition, corresponding to a Forrest stage I b upper gastrointestinal bleed. The bleeding was successfully stopped endoscopically by local injection of adrenaline and the application of polymer powder. A CT scan of the thorax and abdomen showed no signs of active bleeding or free abdominal fluid . The known hepatic and peritoneal metastasis were described as constant in size, but increasingly necrotic compared to a previous CT scan. Due to a renewed drop in the hemoglobin concentration during the course of the day, a repeat gastroscopy was performed. This time, it showed diffuse bleeding without a circumscribed source. As a result, we acted to stabilize the coagulopathy by transfusing the patient with 9 units of pRBCs, 6 units of fresh frozen plasma (FFPs), and 6 units of platelet concentrates. In addition, the patient received 3 g of fibrinogen and 4000 IU of PPSB®, a prothrombin complex concentrate containing the coagulation factors II, VII, X, and IX.\nOn the second day after admission, a temporary improvement in the clinical condition of the patient was observed. It was possible to extubate the patient, who was hemodynamically stable with no signs of active bleeding. A phase of atrial fibrillation was cardioverted following treatment with a beta blocker, digoxin, and amiodarone. On the third day following her admission, the patient's condition deteriorated rapidly with the occurrence of fever, gross hematuria, and decreased oxygen saturation. A delayed hemolytic transfusion reaction was suspected, and positive Rh antibodies (anti-c antibody) were detected. Clinically as well as biochemically, the patient was suffering from a hemolysis with a decline of the hemoglobin concentration to 4.8 mg/dl and an increase of lactate dehydrogenase (LDH) to 3842.0 U/l. Given the lack of a septic focus, only a marginal increase in the inflammatory parameters, and pending blood culture results, no antibiotic treatment or surgical therapy was initiated. Due to imminent respiratory failure, the patient was reintubated. Vasopressors, atropine, and crystalloid solutions were administered to treat bradycardia and shock. However, the patient died on the same evening, following an unsuccessful cardiopulmonary resuscitation.\nThe results of blood cultures taken on the day of the patient's death revealed gram-labile rods without bacterial growth after two days. The subsequent external analysis confirmed bacteremia with C. perfringens and the detection of the alpha toxin gene by polymerase chain reaction, but without any traces of the beta toxin, enterotoxin, epsilon toxin, or iota toxin. The autopsy of the patient revealed a 6 cm sized local recurrence of the GIST and multiple necrotic liver metastases. In addition, a diffuse spread of C. perfringens in multiple organs with advanced tissue lysis was histologically confirmed . The mucosal ulcer of the jejunal interposition was located 1.5 cm distal to the esophagojejunal anastomosis, which itself was intact. Death due to a septic-toxic shock caused by C. perfringens sepsis was determined as the cause of death. A contamination of the administered blood products with C. perfringens as the source of the infection was excluded by a subsequent analysis, which was confirmed by an external laboratory.", + "fulltext_subclaims": [ + "An 81-year-old female patient presented to the emergency department with acute onset of hematemesis and melena.", + "On admission, the patient appeared to have a poor general health condition and was hemodynamically compromised.", + "The initial laboratory exams revealed a hemoglobin concentration of 7.7 mg/dl.", + "The patient had a history of a 6.5 cm gastrointestinal stromal tumor (GIST) of the cardia.", + "The patient initially received downsizing treatment with imatinib 400 mg/d.", + "The patient underwent surgical resection of the gastroesophageal junction and reconstruction with a jejunal interposition (Merendino procedure) 4 years earlier.", + "Histopathological studies of the tumor revealed a T3-tumor with a positive c-Kit mutation in exon-11.", + "The Ki-67 proliferation rate was 15%.", + "The risk for disease progression based on Miettinen's criteria was determined as high.", + "The patient was placed on 1st line adjuvant therapy with imatinib 400 mg/d.", + "After two years on 1st line treatment, the patient developed hepatic and peritoneal metastasis.", + "The patient was placed on sunitinib as 2nd line therapy for metastatic GIST.", + "Treatment with a proton pump inhibitor (PPI) was suspended for an unknown reason two years prior to presentation.", + "The patient was immediately transferred to the intensive care unit.", + "The patient was intubated and received two units of packed red blood cells.", + "An emergency gastroscopy revealed active bleeding from a vessel stump in the jejunal interposition.", + "The bleeding was successfully stopped endoscopically by local injection of adrenaline and the application of polymer powder.", + "A CT scan showed no signs of active bleeding or free abdominal fluid.", + "The known hepatic and peritoneal metastasis were described as constant in size.", + "The metastasis were increasingly necrotic compared to a previous CT scan.", + "A repeat gastroscopy showed diffuse bleeding without a circumscribed source.", + "The patient received 9 units of packed red blood cells, 6 units of fresh frozen plasma, and 6 units of platelet concentrates.", + "The patient received 3 g of fibrinogen and 4000 IU of PPSB®.", + "On the second day after admission, a temporary improvement in the clinical condition was observed.", + "The patient was extubated and was hemodynamically stable with no signs of active bleeding.", + "A phase of atrial fibrillation was cardioverted following treatment with a beta blocker, digoxin, and amiodarone.", + "On the third day following admission, the patient's condition deteriorated rapidly with fever, gross hematuria, and decreased oxygen saturation.", + "A delayed hemolytic transfusion reaction was suspected.", + "Positive Rh antibodies (anti-c antibody) were detected.", + "The patient was suffering from hemolysis with a decline of the hemoglobin concentration to 4.8 mg/dl.", + "The lactate dehydrogenase (LDH) increased to 3842.0 U/l.", + "No antibiotic treatment or surgical therapy was initiated.", + "The patient was reintubated due to imminent respiratory failure.", + "Vasopressors, atropine, and crystalloid solutions were administered.", + "The patient died on the same evening following an unsuccessful cardiopulmonary resuscitation.", + "The results of blood cultures revealed gram-labile rods without bacterial growth after two days.", + "The subsequent external analysis confirmed bacteremia with C. perfringens.", + "The detection of the alpha toxin gene by polymerase chain reaction was confirmed.", + "The autopsy revealed a 6 cm sized local recurrence of the GIST.", + "Multiple necrotic liver metastases were found.", + "A diffuse spread of C. perfringens in multiple organs with advanced tissue lysis was histologically confirmed.", + "The mucosal ulcer of the jejunal interposition was located 1.5 cm distal to the esophagojejunal anastomosis.", + "The esophagojejunal anastomosis itself was intact.", + "Death due to a septic-toxic shock caused by C. perfringens sepsis was determined as the cause of death.", + "A contamination of the administered blood products with C. perfringens as the source of the infection was excluded." + ], + "summary": "An 81-year-old female patient was acutely admitted to our hospital due to hematemesis and melena. She had a history of metastatic gastrointestinal stromal tumor, for which she was receiving second line treatment with sunitinib. She had also undergone a Merendino procedure 4 years prior to presentation. The patient underwent emergency gastroscopy, which revealed a bleeding ulcer in the jejunal interposition. Despite initial endoscopic control of the bleeding and transfusion of blood products, the hemoglobin level continued to drop, and the patient was treated for an assumed hemolytic transfusion reaction. The patient died 3 days following admission, and the results of blood cultures later confirmed a Clostridium perfringens septicemia. The postmortem examination revealed a diffuse spread of Clostridium perfringens to multiple organs.", + "summary_subclaims": [ + "An 81-year-old female patient was acutely admitted to our hospital due to hematemesis and melena.", + "She had a history of metastatic gastrointestinal stromal tumor.", + "She was receiving second line treatment with sunitinib.", + "She had undergone a Merendino procedure 4 years prior to presentation.", + "The patient underwent emergency gastroscopy.", + "Emergency gastroscopy revealed a bleeding ulcer in the jejunal interposition.", + "Initial endoscopic control of the bleeding was performed.", + "Blood products were transfused.", + "The hemoglobin level continued to drop.", + "The patient was treated for an assumed hemolytic transfusion reaction.", + "The patient died 3 days following admission.", + "Blood cultures later confirmed Clostridium perfringens septicemia.", + "The postmortem examination revealed a diffuse spread of Clostridium perfringens to multiple organs." + ] + }, + { + "id": "multiclinsum_test_2461_en.txt", + "fulltext": "We report a case of a 58-year-old male with peripheral artery disease. Although he had a 10-year history of intermittent claudication, he had not visited a hospital for consultation previously. When he experienced a stroke and was admitted to our hospital, an MRI revealed left carotid stenosis, and stenting was performed. During admission, arteriosclerosis obliterans (ASO) was detected. The ankle brachial pressure index (ABI) was 0.61 in his right limb and 0.76 in his left limb. He also had a history of depression, alcoholism, Chronic obstructive pulmonary disease (FEV1.0 was 45.7%, FEV1.0 predicted was 54.8%), hypertension, and chronic renal failure.\nAfter treatment for the stroke, he was referred to our heart and vascular team because of the ASO. An angiography through the left radial artery showed total occlusion of the right common iliac artery, 50% stenosis of the left common iliac artery, and 90% stenosis of the left extra iliac artery. Coronary angiography (CAG) was simultaneously performed because he had shortness of breath during exertion. The CAG showed three-vessel disease (#1, 100%; #5, 50%; #6, 90%; #11, 100%). The circumflex artery was perfused by the collaterals, but quite small, and right coronary artery, which was filled with collaterals, supplied the posterolateral area . Bilateral ITA demonstrated a good collateral pathway to both external iliac arteries.\nEchocardiogram revealed that Left ventricular ejection fraction was 45% by modified Simpson method, the wall motion in the base and mid potion from the inferior to posterior lesion, and there was no significant valvular disease. Preoperative evaluation according to Euro score 2 and STS score were 1.226% and 2.09% respectively.\nOur heart and vascular team concluded that CABG was recommended with bilateral ITA after a percutaneous transluminal angioplasty (PTA) because it was thought that keeping the access route for Intra-Aortic Balloon Pumping (IABP) was important and ITAs serve as good collaterals to both femoral arteries. In case of PTA failure of the right iliac artery occlusion, a concomitant procedure such as a femoro-femoral crossover bypass was planned for the CABG.\nAlthough the PTA to the left common iliac artery and the left extra iliac artery with stenting was successfully performed, the PTA to the occlusive lesion of the right iliac artery was not successful. Therefore, CABG with a femoro-femoral crossover bypass was performed. The left ITA was harvested, followed by the right ITA, both with a skeletonized technique. The patient underwent off-pump CABG with the left ITA, which was anastomosed to the left anterior descending artery, and the right ITA, which was anastomosed to the proximal part of the posterior descending branch. Then, the femoro-femoral crossover bypass was performed with an 8-mm ringed polytetrafluoroethylene graft. Anastomosis to the left common femoral artery in endo-to-side fashion was followed by anastomosis to the right common femoral artery in endo-to-side fashion. During the operation, the blood pressure was stable with norepinephrine (range: 0–0.06 µg/kg/min) and monitoring of the cardiac output revealed a flow of 3.3–4.3 L/min (cardiac index was 1.6–2.1 L/min/m2). The interval between the clamping of the right ITA and starting perfusion to the right femoral artery was 3 h and 47 min.\nAfter the operation, the patient’s condition was stable. Two hours after the operation, he was extubated in the intensive care unit, and no significant findings in his legs were noted. He underwent a routine postoperative blood test and showed an elevated creatine kinase level (2669 U/L), which peaked out at 7177 U/Lon postoperative day 1. Subsequently, it decreased gradually to the normal range for 10 days. Postoperative angiography showed that all ITA grafts and the femoro-femoral crossover bypass were patent. The intermittent claudication symptoms improved, and the ABI was 0.95 in the right side and 0.88 in the left side. He is followed as outpatients without symptom of angina 6 months after surgery.", + "fulltext_subclaims": [ + "The patient was a 58-year-old male.", + "He had a 10-year history of intermittent claudication.", + "He had not visited a hospital for consultation previously.", + "He experienced a stroke and was admitted to the hospital.", + "An MRI revealed left carotid stenosis.", + "Stenting was performed.", + "Arteriosclerosis obliterans (ASO) was detected during admission.", + "The ankle brachial pressure index (ABI) was 0.61 in his right limb.", + "The ABI was 0.76 in his left limb.", + "He had a history of depression.", + "He had a history of alcoholism.", + "He had Chronic obstructive pulmonary disease.", + "His FEV1.0 was 45.7%.", + "His FEV1.0 predicted was 54.8%.", + "He had a history of hypertension.", + "He had chronic renal failure.", + "An angiography through the left radial artery showed total occlusion of the right common iliac artery.", + "The angiography showed 50% stenosis of the left common iliac artery.", + "The angiography showed 90% stenosis of the left extra iliac artery.", + "Coronary angiography (CAG) showed three-vessel disease.", + "The CAG showed 100% stenosis in vessel #1.", + "The CAG showed 50% stenosis in vessel #5.", + "The CAG showed 90% stenosis in vessel #6.", + "The CAG showed 100% stenosis in vessel #11.", + "The circumflex artery was perfused by collaterals.", + "The circumflex artery was quite small.", + "The right coronary artery was filled with collaterals.", + "The right coronary artery supplied the posterolateral area.", + "Bilateral ITA demonstrated a good collateral pathway to both external iliac arteries.", + "The echocardiogram showed a left ventricular ejection fraction of 45%.", + "The wall motion in the base and mid portion from the inferior to posterior lesion was noted.", + "There was no significant valvular disease.", + "The Euro score 2 was 1.226%.", + "The STS score was 2.09%.", + "The heart and vascular team concluded that CABG was recommended with bilateral ITA.", + "The recommendation was after a percutaneous transluminal angioplasty (PTA).", + "The PTA to the left common iliac artery and the left extra iliac artery with stenting was successfully performed.", + "The PTA to the occlusive lesion of the right iliac artery was not successful.", + "CABG with a femoro-femoral crossover bypass was performed.", + "The left ITA was harvested.", + "The right ITA was harvested.", + "Both ITAs were harvested with a skeletonized technique.", + "The patient underwent off-pump CABG with the left ITA.", + "The left ITA was anastomosed to the left anterior descending artery.", + "The right ITA was anastomosed to the proximal part of the posterior descending branch.", + "The femoro-femoral crossover bypass was performed with an 8-mm ringed polytetrafluoroethylene graft.", + "Anastomosis to the left common femoral artery was in endo-to-side fashion.", + "Anastomosis to the right common femoral artery was in endo-to-side fashion.", + "The interval between the clamping of the right ITA and starting perfusion to the right femoral artery was 3 h and 47 min.", + "The patient’s condition was stable after the operation.", + "He was extubated in the intensive care unit two hours after the operation.", + "No significant findings in his legs were noted.", + "The creatine kinase level was 2669 U/L two hours after the operation.", + "The creatine kinase level peaked at 7177 U/L on postoperative day 1.", + "The creatine kinase level decreased gradually to the normal range for 10 days.", + "Postoperative angiography showed that all ITA grafts were patent.", + "Postoperative angiography showed that the femoro-femoral crossover bypass was patent.", + "The intermittent claudication symptoms improved.", + "The ABI was 0.95 in the right side.", + "The ABI was 0.88 in the left side.", + "He is followed as outpatients without symptom of angina 6 months after surgery." + ], + "summary": "A 58-year-old man was admitted to our department with claudication and dyspnea upon exertion. He was diagnosed with right common iliac artery obstruction and 90% stenosis of the left common iliac artery. Coronary angiography revealed three-vessel disease with 50% stenosis of the left main trunk. The bilateral ITA showed a rich collateral flow to the lower extremities. Hybrid single staged repair with percutaneous transluminal angioplasty for the left iliac lesion was performed, followed by off-pump coronary artery bypass grafting (CABG) and femoro-femoral crossover bypass. Postoperative angiography revealed that all grafts were patent. The postoperative course was uneventful, except that the patient's creatinine kinase level increased to 7177 U/L on postoperative day 1.", + "summary_subclaims": [ + "The patient is a 58-year-old man.", + "He was admitted with claudication.", + "He had dyspnea upon exertion.", + "He was diagnosed with right common iliac artery obstruction.", + "He had 90% stenosis of the left common iliac artery.", + "Coronary angiography revealed three-vessel disease.", + "The left main trunk had 50% stenosis.", + "The bilateral ITA showed a rich collateral flow to the lower extremities.", + "Hybrid single staged repair with percutaneous transluminal angioplasty for the left iliac lesion was performed.", + "Off-pump coronary artery bypass grafting was performed.", + "A femoro-femoral crossover bypass was performed.", + "Postoperative angiography revealed that all grafts were patent.", + "The postoperative course was uneventful.", + "The patient's creatinine kinase level increased to 7177 U/L on postoperative day 1." + ] + }, + { + "id": "multiclinsum_test_369_en.txt", + "fulltext": "A 36-year-old Asian woman was admitted to our hospital on April 25, 2016 with localized pain in the left anterior tibial region for 15 years.\nThe patient had visited several hospitals in the past 15 years but was diagnosed with venous thrombosis, which did not improve with conservative treatment such as analgetics. Over the past three years, the patient's pain had progressively worsened, and was exacerbated by touch, temperature changes and mood swings. In addition, the patient often had a poor sleep at night because of the pain.\nNo special history of past illness.\nThere was no personal history of GT or any other family medical history.\nPhysical examination revealed mildly localized swelling on the on left leg along with tenderness in a 50 mm × 30 mm area of skin on the anterior medial aspect of her left lower extremity, with no ulceration or warmth.\nNo obvious abnormality was found in laboratory examination.", + "fulltext_subclaims": [ + "The patient is a 36-year-old Asian woman.", + "She was admitted to the hospital on April 25, 2016.", + "She had localized pain in the left anterior tibial region for 15 years.", + "She had visited several hospitals in the past 15 years.", + "She was diagnosed with venous thrombosis.", + "She did not improve with conservative treatment such as analgetics.", + "Her pain had progressively worsened over the past three years.", + "Her pain was exacerbated by touch.", + "Her pain was exacerbated by temperature changes.", + "Her pain was exacerbated by mood swings.", + "She often had poor sleep at night because of the pain.", + "There was no special history of past illness.", + "There was no personal history of GT.", + "There was no other family medical history.", + "Physical examination revealed mildly localized swelling on the left leg.", + "Tenderness was found in a 50 mm × 30 mm area of skin on the anterior medial aspect of her left lower extremity.", + "There was no ulceration.", + "There was no warmth.", + "No obvious abnormality was found in laboratory examination." + ], + "summary": "The patient was a A 36-year-old woman who had suffered from localized pain in her left lower leg for 15 years. After a complete physical examination, a glomus tumor on her lower leg was considered and removed surgically. The specimen was pathologically diagnosed as a glomus tumor. There was no relapse at a 4-year follow-up.", + "summary_subclaims": [ + "The patient was a 36-year-old woman.", + "She had suffered from localized pain in her left lower leg for 15 years.", + "A glomus tumor on her lower leg was considered.", + "The tumor was removed surgically.", + "The specimen was pathologically diagnosed as a glomus tumor.", + "There was no relapse at a 4-year follow-up." + ] + }, + { + "id": "multiclinsum_test_403_en.txt", + "fulltext": "A 15-year-old Indian girl was referred to our Department of Pedodontics and Preventive Dentistry with the chief complaint of unerupted teeth. Her medical history revealed delayed closure of the anterior fontanelle, a fracture of her right humerus at three years of age and delayed puberty. Our patient was poorly built, short statured, moderately-nourished with a concave facial profile. She had shrugged shoulders with more than normal mobility of the shoulder girdle. Oral findings include Class III malocclusion with anterior and posterior crossbite and retained deciduous teeth .\nAn orthopantomogram revealed multiple unerupted permanent teeth and supernumerary teeth in the mandibular anterior region . A lateral cephalograph revealed wide skull sutures . The posteroanterior view of a chest radiograph revealed the absence of clavicles and a bell-shaped ribcage. Based on these clinical and radiographic findings, a diagnosis of cleidocranial dysplasia was made. However, her chromosomal analysis revealed normal female karyotype 46XX.\nA multidisciplinary dental approach involving oral and maxillofacial surgeons, orthodontists and pedodontists was followed in our case. Space management and proper eruption of her permanent teeth for aesthetic purposes were planned. Under general anesthesia, all her primary mandibular anterior teeth and supernumerary teeth were removed. Permanent anterior teeth were exposed surgically and orthodontic brackets and ligature wires were placed for traction for the permanent teeth to erupt, along with a lingual arch appliance to prevent the arch collapsing . The same procedure was performed in the maxillary anterior region after two months . Our patient's self image was taken care of through behavior management and counseling.\nAfter six months, the permanent teeth were erupting assisted by the orthodontic brackets and arch wire . Despite thorough oral hygiene instructions and maintenance during every follow-up visit, our patient suffered from poor oral hygiene due to the bonded orthodontic brackets and wires.\nUnder an aggressive oral hygiene maintenance program, our patient is followed-up periodically for further treatment.", + "fulltext_subclaims": [ + "A 15-year-old Indian girl was referred to our Department of Pedodontics and Preventive Dentistry with the chief complaint of unerupted teeth.", + "Her medical history revealed delayed closure of the anterior fontanelle.", + "Her medical history revealed a fracture of her right humerus at three years of age.", + "Her medical history revealed delayed puberty.", + "Our patient was short statured.", + "She had shrugged shoulders with more than normal mobility of the shoulder girdle.", + "Oral findings include Class III malocclusion.", + "Oral findings include anterior and posterior crossbite.", + "Oral findings include retained deciduous teeth.", + "An orthopantomogram revealed multiple unerupted permanent teeth.", + "An orthopantomogram revealed supernumerary teeth in the mandibular anterior region.", + "A lateral cephalograph revealed wide skull sutures.", + "The posteroanterior view of a chest radiograph revealed the absence of clavicles.", + "The posteroanterior view of a chest radiograph revealed a bell-shaped ribcage.", + "A diagnosis of cleidocranial dysplasia was made.", + "Her chromosomal analysis revealed normal female karyotype 46XX.", + "A multidisciplinary dental approach involving oral and maxillofacial surgeons, orthodontists and pedodontists was followed.", + "Space management and proper eruption of her permanent teeth for aesthetic purposes were planned.", + "Under general anesthesia, all her primary mandibular anterior teeth and supernumerary teeth were removed.", + "Permanent anterior teeth were exposed surgically.", + "Orthodontic brackets and ligature wires were placed for traction for the permanent teeth to erupt.", + "A lingual arch appliance was placed to prevent the arch collapsing.", + "The same procedure was performed in the maxillary anterior region after two months.", + "Our patient's self image was taken care of through behavior management and counseling.", + "After six months, the permanent teeth were erupting assisted by the orthodontic brackets and arch wire.", + "Our patient suffered from poor oral hygiene due to the bonded orthodontic brackets and wires.", + "Our patient is followed-up periodically for further treatment." + ], + "summary": "Our patient, a 15-year-old Indian girl, presented with the typical features of prolonged retention of deciduous dentition and delayed eruption of permanent teeth, that is, mandibular prognathism along with other skeletal abnormalities like shrugged shoulder and the absence of clavicles. A multidisciplinary approach was followed, comprising orthodontic, surgical and pedodontic teams for management.", + "summary_subclaims": [ + "The patient is a 15-year-old Indian girl.", + "She presented with prolonged retention of deciduous dentition.", + "She had delayed eruption of permanent teeth.", + "She had mandibular prognathism.", + "She had shrugged shoulders.", + "She had absence of clavicles.", + "A multidisciplinary approach was followed.", + "The approach included orthodontic, surgical, and pedodontic teams." + ] + }, + { + "id": "multiclinsum_test_1687_en.txt", + "fulltext": "A 21-year-old female presented with 3 months of severe, left L5 radicular pain accompanied by L5 hypoesthesia to light touch and decreased pin-perception, without weakness. MR showed a dumbbell-shaped, heterogenously enhancing lesion centered in the left L5/S1 foramen, measuring 4.5 cm × 4 cm . The tumor displaced the thecal sac anterolaterally to the right and also involved the posterolateral L5 vertebral body/left L5 pedicle/lamina along with superior extension (i.e., toward L4/5 into the retroperitoneal space above the sacral alar). Multiple tortuous vessels extended along the cauda equina .\nThrough a L4 and L5 hemilaminectomy with a left L5/S1 facetectomy, a gross total excision was accomplished. On opening of the dura, a black, hemorrhagic tumor was visualized. Postoperatively, the patient’s radicular pain resolved, she retained full motor and regained normal sensory function in the left L5 distribution.\nWithin 4 postoperative months and despite a negative PETCT obtained 3 months after surgery, the lesion recurred. The patient presented with sudden onset lower back pain with recurrent radiculopathy. Within days, she also developed a severe bifrontal headache, vomiting, photophobia, visual loss (i.e., only able to differentiate between light and dark), and a generalized seizure. The patient also developed distal lower limb weakness, bilateral abducens nerve palsies, facial diplegia, bilateral trigeminal nerve palsies, and dysarthria. The fundus exam showed florid papilledema. The emergent holo-spinal and brain MRI showed diffuse leptomeningeal enhancement along the full length of the spinal cord extending to the brainstem and cerebrum. There was also a focal recurrent epidural soft-tissue lesion within the left posterolateral aspect at L4/5 measuring 12 mm × 10 mm .\nA CT-guided lumbar puncture revealed only gelatinous material and core biopsy samples were taken. CSF studies showed high protein, low glucose, but no organisms. A frontal external ventricular drain was placed, and later converted to a ventriculoperitoneal shunt Craniospinal irradiation was administered after EVD insertion. Notably, the patient was discharged wheelchair-bound 3 months later.\nTumor sections from both treatment periods showed a pigmented epithelioid to spindled cell tumor composed of cellular nodules, trabeculae and fascicles characterized by moderate nuclear pleomorphism, variably prominent nucleoli, and a moderate amount of eosinophilic cytoplasm . The initial specimen had scattered nuclear grooves and intra-nuclear pseudo-inclusions, with only rare mitoses observed. No psammoma bodies were seen. The pigment was demonstrated to be melanin (Schmorl’s positive, Perl’s negative). The tumor cells were strongly positive for S100, HMB45, melanin-A and SOX10 and negative for EMA, AE1/3, CAM5.2, and GFAP. The proliferative rate was 6% (Ki67). These findings were consistent with a diagnosis of a MMNST. The secondary tumor showed MMNST, identical in morphology to that seen from the primary excision and included increased areas of tumor necrosis with a high mitotic count of up to 14 per high power field (×400). Further, the Ki67 had increased significantly and was estimated at 40% .", + "fulltext_subclaims": [ + "The patient is a 21-year-old female.", + "She had 3 months of severe, left L5 radicular pain.", + "She had L5 hypoesthesia to light touch.", + "She had decreased pin-perception.", + "There was no weakness.", + "MR showed a dumbbell-shaped, heterogenously enhancing lesion centered in the left L5/S1 foramen.", + "The tumor measured 4.5 cm × 4 cm.", + "The tumor displaced the thecal sac anterolaterally to the right.", + "The tumor involved the posterolateral L5 vertebral body/left L5 pedicle/lamina.", + "The tumor extended superiorly toward L4/5 into the retroperitoneal space above the sacral alar.", + "Multiple tortuous vessels extended along the cauda equina.", + "A L4 and L5 hemilaminectomy with a left L5/S1 facetectomy was performed.", + "A gross total excision was accomplished.", + "On opening of the dura, a black, hemorrhagic tumor was visualized.", + "Postoperatively, the patient’s radicular pain resolved.", + "She retained full motor function.", + "She regained normal sensory function in the left L5 distribution.", + "Within 4 postoperative months, the lesion recurred.", + "A PETCT obtained 3 months after surgery was negative.", + "The patient presented with sudden onset lower back pain with recurrent radiculopathy.", + "She developed a severe bifrontal headache.", + "She had vomiting.", + "She had photophobia.", + "She had visual loss (only able to differentiate between light and dark).", + "She had a generalized seizure.", + "She developed distal lower limb weakness.", + "She had bilateral abducens nerve palsies.", + "She had facial diplegia.", + "She had bilateral trigeminal nerve palsies.", + "She had dysarthria.", + "The fundus exam showed florid papilledema.", + "The emergent holo-spinal and brain MRI showed diffuse leptomeningeal enhancement along the full length of the spinal cord extending to the brainstem and cerebrum.", + "There was a focal recurrent epidural soft-tissue lesion within the left posterolateral aspect at L4/5 measuring 12 mm × 10 mm.", + "A CT-guided lumbar puncture revealed only gelatinous material.", + "Core biopsy samples were taken.", + "CSF studies showed high protein.", + "CSF studies showed low glucose.", + "No organisms were found in the CSF.", + "A frontal external ventricular drain was placed.", + "The EVD was later converted to a ventriculoperitoneal shunt.", + "Craniospinal irradiation was administered after EVD insertion.", + "The patient was discharged wheelchair-bound 3 months later.", + "Tumor sections from both treatment periods showed a pigmented epithelioid to spindled cell tumor composed of cellular nodules, trabeculae and fascicles.", + "The tumor was characterized by moderate nuclear pleomorphism.", + "The tumor had variably prominent nucleoli.", + "The tumor had a moderate amount of eosinophilic cytoplasm.", + "The initial specimen had scattered nuclear grooves and intra-nuclear pseudo-inclusions.", + "The initial specimen had only rare mitoses observed.", + "No psammoma bodies were seen.", + "The pigment was demonstrated to be melanin (Schmorl’s positive, Perl’s negative).", + "The tumor cells were strongly positive for S100.", + "The tumor cells were strongly positive for HMB45.", + "The tumor cells were strongly positive for melanin-A.", + "The tumor cells were strongly positive for SOX10.", + "The tumor cells were negative for EMA.", + "The tumor cells were negative for AE1/3.", + "The tumor cells were negative for CAM5.2.", + "The tumor cells were negative for GFAP.", + "The proliferative rate was 6% (Ki67).", + "These findings were consistent with a diagnosis of a MMNST.", + "The secondary tumor showed MMNST, identical in morphology to that seen from the primary excision.", + "The secondary tumor included increased areas of tumor necrosis.", + "The secondary tumor had a high mitotic count of up to 14 per high power field (×400).", + "The Ki67 had increased significantly and was estimated at 40%." + ], + "summary": "A 21-year-old female presented with 3 months of severe left L5 distribution radicular leg pain and sensory loss. The MR revealed a dumbbell-shaped, heterogenously enhancing lesion centered on the left L5/S1 foramen; the intracanalicular component displaced the thecal sac to the right, while the extraforaminal portion of tumor extended anteriorly into the retroperitoneal space. Gross total resection was performed after a L5/S1 facetectomy. In the immediate postoperative period there were no complications, and the patient had full lower limb power. Four months later, the patient experienced generalized seizures, headache, and multiple cranial nerve palsies due to local and diffuse CNS dissemination. The MRI of the brain and whole spine revealed diffuse leptomeningeal enhancement along the full length of the spinal cord into the brainstem and cerebrum along with a focally recurrent epidural soft-tissue lesion located posterolaterally on the left at the L4/5 level (i.e., measuring 12 mm × 10 mm). An external ventricular drain and subsequent ventriculoperitoneal shunt were inserted, followed by craniospinal irradiation. She was discharged 3 months later with residual distal lower limb weakness.", + "summary_subclaims": [ + "The patient is a 21-year-old female.", + "She had 3 months of severe left L5 distribution radicular leg pain.", + "She had sensory loss.", + "The MR showed a dumbbell-shaped, heterogenously enhancing lesion centered on the left L5/S1 foramen.", + "The intracanalicular component displaced the thecal sac to the right.", + "The extraforaminal portion of the tumor extended anteriorly into the retroperitoneal space.", + "Gross total resection was performed after a L5/S1 facetectomy.", + "In the immediate postoperative period, there were no complications.", + "The patient had full lower limb power.", + "Four months later, she experienced generalized seizures.", + "She had headache.", + "She had multiple cranial nerve palsies.", + "The cause was local and diffuse CNS dissemination.", + "The MRI of the brain and whole spine showed diffuse leptomeningeal enhancement along the full length of the spinal cord into the brainstem and cerebrum.", + "There was a focally recurrent epidural soft-tissue lesion located posterolaterally on the left at the L4/5 level.", + "The lesion measured 12 mm × 10 mm.", + "An external ventricular drain was inserted.", + "A ventriculoperitoneal shunt was inserted.", + "Craniospinal irradiation was performed.", + "She was discharged 3 months later.", + "She had residual distal lower limb weakness." + ] + }, + { + "id": "multiclinsum_test_3288_en.txt", + "fulltext": "We present a 40-year-old female, a gravida-9 para-7+1, who previously underwent an interval bilateral tubal ligation (BTL) in December 2016 during a community outreach program, through a mini laparotomy. She had seven previous successful pregnancies and an ectopic pregnancy in October 2019, for which she had an exploratory laparotomy and salpingectomy done for a left-ruptured tubal ectopic pregnancy in November 2018. She presented at a university teaching hospital in northern Uganda on October 20, 2021, with acute abdominal pain for 2 days and amenorrhea for 6 weeks, with no vaginal bleeding. She was fully conscious, in pain, anxious, afebrile, and hemodynamically stable, with a pulse rate of 98 beats per minute and a blood pressure of 121/78 mmHg. She had generalized abdominal tenderness, guarding and rebound tenderness, and cervical motion tenderness. Laboratory investigations revealed a positive urine pregnancy (HCG) test and a hemoglobin level of 12.9 g/dL with normal platelet count. A trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass, free fluid in the Cul-de-sac measuring 5.2 centimeters deep, and an empty uterine cavity. A diagnosis of ruptured right tubal ectopic pregnancy was made, and the patient was counseled and consented to an emergent exploratory laparotomy. On exploratory laparotomy, approximately 300 mL of blood were found in the peritoneal cavity. A ruptured right distal tube containing a well-circumscribed mass was also found. There was also evidence of a previous right tubal ligation and left salpingectomy with a normal uterus and ovaries. The blood was evacuated, and a right total salpingectomy was done. The excised right tube containing the mass (gestational product) was sent for histological examination. Histopathology revealed chorionic villi and hemorrhagic vascular decidual tissue in the fallopian tube, features suggestive of tubal ectopic pregnancy. Post-operative patient management was uneventful. However, the couple expressed their dismay about the two ectopic pregnancies and dissatisfaction with the previous BTL, as well as concerns about having sex in the future in fear of subsequent ectopic pregnancies. They were counseled to relieve their fears about sex and future ectopic pregnancies.", + "fulltext_subclaims": [ + "The patient is a 40-year-old female.", + "She is gravida-9 para-7+1.", + "She previously underwent an interval bilateral tubal ligation in December 2016.", + "The bilateral tubal ligation was performed through a mini laparotomy.", + "She had seven previous successful pregnancies.", + "She had an ectopic pregnancy in October 2019.", + "She had an exploratory laparotomy and salpingectomy in November 2018.", + "The salpingectomy was done for a left-ruptured tubal ectopic pregnancy.", + "She presented at a university teaching hospital in northern Uganda on October 20, 2021.", + "She had acute abdominal pain for 2 days.", + "She had amenorrhea for 6 weeks.", + "She had no vaginal bleeding.", + "She was fully conscious.", + "She was in pain.", + "She was anxious.", + "She was afebrile.", + "She was hemodynamically stable.", + "Her pulse rate was 98 beats per minute.", + "Her blood pressure was 121/78 mmHg.", + "She had generalized abdominal tenderness.", + "She had guarding and rebound tenderness.", + "She had cervical motion tenderness.", + "A positive urine pregnancy (HCG) test was noted.", + "Her hemoglobin level was 12.9 g/dL.", + "Her platelet count was normal.", + "A trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass.", + "The ultrasound showed free fluid in the Cul-de-sac measuring 5.2 centimeters deep.", + "The ultrasound showed an empty uterine cavity.", + "A diagnosis of ruptured right tubal ectopic pregnancy was made.", + "The patient was counseled and consented to an emergent exploratory laparotomy.", + "On exploratory laparotomy, approximately 300 mL of blood were found in the peritoneal cavity.", + "A ruptured right distal tube containing a well-circumscribed mass was found.", + "There was evidence of a previous right tubal ligation.", + "There was evidence of a left salpingectomy.", + "The uterus and ovaries were normal.", + "The blood was evacuated.", + "A right total salpingectomy was done.", + "The excised right tube containing the mass was sent for histological examination.", + "Histopathology revealed chorionic villi and hemorrhagic vascular decidual tissue in the fallopian tube.", + "The histopathology findings were suggestive of tubal ectopic pregnancy.", + "Post-operative patient management was uneventful.", + "The couple expressed dismay about the two ectopic pregnancies.", + "The couple expressed dissatisfaction with the previous BTL.", + "The couple had concerns about having sex in the future in fear of subsequent ectopic pregnancies.", + "They were counseled to relieve their fears about sex and future ectopic pregnancies." + ], + "summary": "A 40-year-old female, with 7 living children, who previously underwent an interval BTL, presented with acute abdominal pain for 2 days and amenorrhea for 6 weeks. She was stable but had generalized abdominal tenderness, guarding and rebound tenderness, and cervical motion tenderness. Her urine HCG was positive, and a trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass, free fluid in the Cul-de-sac, and an empty uterine cavity, consistent with a ruptured right ectopic pregnancy. An emergency exploratory laparotomy was done with findings of a ruptured right distal tube containing products of conception, hemoperitoneum, and previous tubal ligation and left salpingectomy. A right total salpingectomy was done, and the excised right tube containing the mass was sent for histological examination, which revealed chorionic villi and hemorrhagic vascular decidual tissue in the fallopian tube, features suggestive of tubal ectopic pregnancy.", + "summary_subclaims": [ + "The patient is a 40-year-old female.", + "She has 7 living children.", + "She previously underwent an interval BTL.", + "She presented with acute abdominal pain for 2 days.", + "She had amenorrhea for 6 weeks.", + "She was stable.", + "She had generalized abdominal tenderness.", + "She had guarding and rebound tenderness.", + "She had cervical motion tenderness.", + "Her urine HCG was positive.", + "A trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass.", + "The ultrasound scan showed free fluid in the Cul-de-sac.", + "The ultrasound scan showed an empty uterine cavity.", + "The findings were consistent with a ruptured right ectopic pregnancy.", + "An emergency exploratory laparotomy was done.", + "The laparotomy findings included a ruptured right distal tube containing products of conception.", + "The laparotomy findings included hemoperitoneum.", + "The laparotomy findings included previous tubal ligation.", + "The laparotomy findings included a left salpingectomy.", + "A right total salpingectomy was done.", + "The excised right tube containing the mass was sent for histological examination.", + "Histological examination revealed chorionic villi in the fallopian tube.", + "Histological examination revealed hemorrhagic vascular decidual tissue in the fallopian tube.", + "The histological findings were suggestive of tubal ectopic pregnancy." + ] + }, + { + "id": "multiclinsum_test_304_en.txt", + "fulltext": "A 2-year-old male presented with fevers, leukocytosis (studies were only positive for leukocytosis with WBC of 179,000/cu.mm), and mild lower extremity weakness. The thoracic CT scan showed a needle-shaped foreign body in the spinal canal at the level of T10 level .\nCT myelography documented the presence of a linear radiopaque foreign body (likely a pin/ needle) in the spinal canal at the T10 level traversing from the right pedicle to the left neural foramen; it appeared to be traversing the anterolateral aspect of the cord with no clear contrast separating it from the cord.\nThe patient underwent a T10 laminectomy for removal of the foreign body that proved to be a medical syringe needle tip . As the needle traversed the spinal canal, intraoperative monitoring including motor evoked potentials was utilized. There were no significant intraoperative changes. Indeed, postoperatively, the patient’s mild lower extremity weakness resolved progressively after 2-week follow-up and his gait improved after 6 weeks from OR date.", + "fulltext_subclaims": [ + "The patient is a 2-year-old male.", + "The patient had fevers.", + "The patient had leukocytosis with a WBC of 179,000/cu.mm.", + "The patient had mild lower extremity weakness.", + "The thoracic CT scan showed a needle-shaped foreign body in the spinal canal at the level of T10.", + "CT myelography documented the presence of a linear radiopaque foreign body in the spinal canal at the T10 level.", + "The foreign body traversed from the right pedicle to the left neural foramen.", + "The foreign body appeared to be traversing the anterolateral aspect of the cord.", + "There was no clear contrast separating the foreign body from the cord.", + "The patient underwent a T10 laminectomy for removal of the foreign body.", + "The foreign body proved to be a medical syringe needle tip.", + "Intraoperative monitoring including motor evoked potentials was utilized.", + "There were no significant intraoperative changes.", + "The patient’s mild lower extremity weakness resolved progressively after 2-week follow-up.", + "The patient’s gait improved after 6 weeks from the OR date." + ], + "summary": "A 2-year-old male presented with a history of intermittent fever and mild lower extremity weakness. Notably, the original infectious workup was negative. However, a noncontrast CT scan later documented a needle-shaped foreign body in the spinal canal at the T10 level. During the T10 laminectomy, a needle (i.e. from a medical syringe) was removed, the patient remained neurologically intact. The foreign body turned out to be a medical syringe needle tip.", + "summary_subclaims": [ + "A 2-year-old male presented with a history of intermittent fever.", + "The patient had mild lower extremity weakness.", + "The original infectious workup was negative.", + "A noncontrast CT scan later documented a needle-shaped foreign body in the spinal canal at the T10 level.", + "During the T10 laminectomy, a needle was removed.", + "The needle was from a medical syringe.", + "The patient remained neurologically intact.", + "The foreign body turned out to be a medical syringe needle tip." + ] + }, + { + "id": "multiclinsum_test_2112_en.txt", + "fulltext": "A 64-year old female presented to the emergency department with sharp retrosternal pain and progressive dyspnea. She had a medical history of coronary artery disease, hypertension, atrial fibrillation, rheumatic mitral valve (MV) disease and stroke with residual left-sided hemiplegia. Transesophageal Echocardiography (TEE) revealed severe MV stenosis (MV area 0.9 cm2 [normal >1cm2]), mild mitral regurgitation (MR), no vegetations, minimal leaflet motion with pronounced thickening, extensive valvular calcification and minimal thickening of the sub-valvular apparatus (Wilkins score 14), no thrombus in the left atrial appendage and preserved left ventricular systolic function.\nLeft heart catheterization revealed a non-obstructive coronary artery disease. Right heart catheterization (RHC) revealed a mean PAP of 71 mmHg and a PCWP of 15 mmHg (Transpulmonary Pressure Gradient [TPG] of 51 mmHg). Given the degree of her PH and rest of her co-morbidities (Society of Thoracic Surgeons’ Surgical mortality risk 31%), a multidisciplinary team approach consisting on advanced heart failure, cardiac surgery, intensive care and cardiac anesthesia team reached the consensus that the patient was not an appropriate candidate for surgical mitral valve replacement, therefore the decision was to perform a percutaneous mitral balloon valvuloplasty (PMBV) in the cardiac catheterization under general anesthesia.\nThe patient was brought to the cardiac catheterization suite, underwent uneventful pre-procedure invasive lines placement (radial arterial line and right internal jugular vein introducer) and induction of general anesthesia with endotracheal tube placement. RHC demonstrated a mean PAP of 61 mmHg and a left atrial pressure of 30 mmHg. TEE revealed a severely dilated right ventricle and MV area of 0.9cm2. Cardiac index by Fick method was 1.97 L/min. Balloon dilation of the MV was performed, improving the effective orifice area to 1.3 cm2, however complicated by severe MR, secondary to a ruptured MV chordae tendineae . The cardiothoracic team was emergently consulted. Once again, the decision was that the patient would not tolerate undergo an emergent mitral valve replacement given her severe PH and other co-morbidities, therefore medical management would be the preferred approach in her case.\nAfter discussion with the cardiology team, the patient was extubated and transferred to the intensive care unit (ICU) with stable hemodynamics (mean systemic arterial pressure 72 mmHg), unchanged PAP, and no signs of pulmonary edema. A pulmonary artery catheter was placed through the existing right internal jugular introducer.\nOvernight, she developed systemic hypotension, requiring vasopressors (vasopressin), with the goal to increase the systemic pressures above the PAP, and inodilators (milrinone), with the goal to decrease the PAP. Cardiac output was borderline low at 3.8 l/minute. Mechanical support in the form of an intra-aortic balloon pump was placed to attempt decrease the MR severity and improve the cardiac output. The new severe MR further exacerbated her PH, which converted into a supra-systemic PH .\nRight ventricular support was initiated in the form of pulmonary vasodilators (intravenous epoprostenol − 2 ng/kg/min- and inhaled nitric oxide − 40 parts per minute- via high flow nasal cannula) and endothelin receptor antagonists (macitentan 10 mg orally, once a day). Remarkably, the patient’s pulmonary mechanics and oxygenation were preserved. At this point, the patient was managed mostly medically. Aggressive diuresis was added to the above-mentioned treatment. Eventually, given a recalcitrant response to maximal medical therapy, the patient and her family opted for hospice care and comfort measures.", + "fulltext_subclaims": [ + "The patient is a 64-year-old female.", + "She presented with sharp retrosternal pain.", + "She had a medical history of coronary artery disease.", + "She had a medical history of hypertension.", + "She had a medical history of atrial fibrillation.", + "She had a medical history of rheumatic mitral valve disease.", + "She had a medical history of stroke with residual left-sided hemiplegia.", + "Transesophageal Echocardiography revealed severe mitral valve stenosis.", + "Transesophageal Echocardiography showed a mitral valve area of 0.9 cm2.", + "Transesophageal Echocardiography showed no vegetations.", + "Transesophageal Echocardiography showed minimal leaflet motion with pronounced thickening.", + "Transesophageal Echocardiography showed extensive valvular calcification.", + "Transesophageal Echocardiography showed minimal thickening of the sub-valvular apparatus.", + "Transesophageal Echocardiography showed no thrombus in the left atrial appendage.", + "Transesophageal Echocardiography showed preserved left ventricular systolic function.", + "Right heart catheterization revealed a mean pulmonary artery pressure of 71 mmHg.", + "Right heart catheterization revealed a pulmonary capillary wedge pressure of 15 mmHg.", + "The transpulmonary pressure gradient was 51 mmHg.", + "The Society of Thoracic Surgeons’ Surgical mortality risk was 31%.", + "The multidisciplinary team reached a consensus that the patient was not an appropriate candidate for surgical mitral valve replacement.", + "The decision was to perform a percutaneous mitral balloon valvuloplasty.", + "The procedure was performed under general anesthesia.", + "TEE revealed a severely dilated right ventricle.", + "TEE revealed a mitral valve area of 0.9 cm2.", + "The cardiac index by Fick method was 1.97 L/min.", + "Balloon dilation of the mitral valve was performed.", + "The effective orifice area improved to 1.3 cm2.", + "The procedure was complicated by severe mitral regurgitation.", + "The severe mitral regurgitation was secondary to a ruptured mitral valve chordae tendineae.", + "The cardiothoracic team was emergently consulted.", + "The decision was that the patient would not tolerate an emergent mitral valve replacement.", + "Medical management was the preferred approach.", + "The patient was extubated.", + "The patient was transferred to the intensive care unit.", + "A pulmonary artery catheter was placed through the existing right internal jugular introducer.", + "The patient developed systemic hypotension.", + "Vasopressors were started.", + "The goal of vasopressors was to increase systemic pressures above the pulmonary artery pressure.", + "Inodilators were started.", + "The goal of inodilators was to decrease pulmonary artery pressure.", + "An intra-aortic balloon pump was placed.", + "The new severe mitral regurgitation further exacerbated her pulmonary hypertension.", + "The pulmonary hypertension converted into a supra-systemic pulmonary hypertension.", + "Right ventricular support was initiated.", + "Intravenous epoprostenol was started.", + "Inhaled nitric oxide was started.", + "Macitentan was started.", + "Aggressive diuresis was added to the treatment.", + "The patient and her family opted for hospice care.", + "The patient and her family opted for comfort measures." + ], + "summary": "We present the perioperative management of a patient with rheumatic mitral valve disease, initially found to have severe PH due to pulmonary venous hypertension, who underwent percutaneous mitral balloon valvuloplasty complicated with mitral chordae rupture, severe mitral regurgitation and supra-systemic PH. Multiple medical therapies and an intra-aortic balloon pump were used as means of non-surgical management of this complication.", + "summary_subclaims": [ + "The patient had rheumatic mitral valve disease.", + "The patient was initially found to have severe PH due to pulmonary venous hypertension.", + "The patient underwent percutaneous mitral balloon valvuloplasty.", + "The procedure was complicated by mitral chordae rupture.", + "The procedure was complicated by severe mitral regurgitation.", + "The procedure was complicated by supra-systemic PH.", + "Multiple medical therapies were used as means of non-surgical management.", + "An intra-aortic balloon pump was used as means of non-surgical management." + ] + }, + { + "id": "multiclinsum_test_661_en.txt", + "fulltext": "A 20-year-old man presented to the outpatient department with a palpable mass in the posterior aspect of his knee for the past 3 years. The mass was painless, gradual in onset, and slowly progressed to a size of 10*9 cm when he presented to the outpatient department. The patient had difficulty in squatting for the last 3 months. On local examination, the mass was non-tender, had soft-to-firm consistency, well-defined edges, was smooth, and non-movable with no visible or palpable pulsations. The mass was non-reducible and was not fixed to the overlying skin. Overlying skin showed no signs of local inflammation. Knee flexion was slightly decreased due to the mass effect of swelling with associated discomfort. Distal pulsations were symmetric with no neural deficit.\nLateral plain radiography of the right knee showed a diffuse, non-specific soft-tissue density, with no evidence of calcifications or connection to the underlying bone. Local ultrasonography revealed a heterogeneously hypoechoic lesion of size 9.6*8.6 cm in the right popliteal fossa increased with internal vascularity and signs of inflammation. No associated knee effusion was noted. Due to financial constraints, magnetic resonance imaging (MRI) could not be performed. The patient was counseled about the importance of obtaining an MRI; informed consent was taken to proceed with an excisional biopsy.\nAn excisional biopsy was performed using a posterior approach. The mass was located between the two heads of gastrocnemius, under the superficial fascia . It was encapsulated with no major adhesions, and separation from the surrounding soft tissue was relatively easy using blunt dissection considering the proximity of the mass to nearby neurovascular structures. A solid and brownish-red mass was excised and sent to a pathologist for further histopathological examination. The mass was well circumscribed and the cut surface showed gray-white myxoid change with a yellowish fatty center with interspersed vascularity . On histopathology, spindle-shaped fibroblasts arranged in fascicular pattern showing “a tissue culture appearance.” Cells were slender, and elongated with oval nuclei and prominent nucleoli. Intervening collagenous stroma shows myxoid changes with a few blood vessels and focal inflammation .\nThere were no neurological or vascular complications post-operatively. Three months post-operatively, the patient showed clinical improvement in symptoms and could squat without discomfort.", + "fulltext_subclaims": [ + "A 20-year-old man presented with a palpable mass in the posterior aspect of his knee for the past 3 years.", + "The mass was painless, gradual in onset, and slowly progressed to a size of 10*9 cm.", + "The patient had difficulty in squatting for the last 3 months.", + "On local examination, the mass was non-tender, had soft-to-firm consistency, well-defined edges, was smooth, and non-movable.", + "The mass was non-reducible and was not fixed to the overlying skin.", + "Overlying skin showed no signs of local inflammation.", + "Knee flexion was slightly decreased due to the mass effect of swelling with associated discomfort.", + "Lateral plain radiography of the right knee showed a diffuse, non-specific soft-tissue density.", + "Local ultrasonography revealed a heterogeneously hypoechoic lesion of size 9.6*8.6 cm in the right popliteal fossa.", + "The lesion showed increased internal vascularity and signs of inflammation.", + "No associated knee effusion was noted.", + "Magnetic resonance imaging could not be performed due to financial constraints.", + "The patient was counseled about the importance of obtaining an MRI.", + "Informed consent was taken to proceed with an excisional biopsy.", + "An excisional biopsy was performed using a posterior approach.", + "The mass was located between the two heads of gastrocnemius, under the superficial fascia.", + "The mass was encapsulated with no major adhesions.", + "Separation from the surrounding soft tissue was relatively easy using blunt dissection.", + "A solid and brownish-red mass was excised.", + "The mass was well circumscribed.", + "The cut surface showed gray-white myxoid change with a yellowish fatty center with interspersed vascularity.", + "On histopathology, spindle-shaped fibroblasts were arranged in a fascicular pattern showing 'a tissue culture appearance.'", + "Cells were slender, elongated with oval nuclei and prominent nucleoli.", + "Intervening collagenous stroma showed myxoid changes with a few blood vessels and focal inflammation.", + "There were no neurological or vascular complications post-operatively.", + "Three months post-operatively, the patient showed clinical improvement in symptoms.", + "The patient could squat without discomfort three months post-operatively." + ], + "summary": "A 20-year-old male man presented to the outpatient department with a solitary palpable mass on the posterior aspect of his right knee for the past 3 years associated with difficulty in squatting for the past 3 months. The mass gradually was well defined and increased gradually in size to the current size of 10*9 cm, irregular soft to firm in consistency, spherical, non-tender, and non-reducible on the posterior aspect of the popliteal fossa. Local ultrasonography showed evidence of heterogeneous hypoechoic lesion with signs of inflammation; underlying bony cortices appeared to be normal. A clinical diagnosis of Baker's cyst was made and an excisional biopsy was performed. Microscopically, histologic sections showed fibroblasts arranged in loose fascicular patterns intermixed with small amount of collagen and myxoid stroma.", + "summary_subclaims": [ + "The patient is a 20-year-old male man.", + "He had a solitary palpable mass on the posterior aspect of his right knee for the past 3 years.", + "The mass was associated with difficulty in squatting for the past 3 months.", + "The mass was well defined and increased gradually in size to 10*9 cm.", + "The mass was irregular, soft to firm in consistency, spherical, non-tender, and non-reducible.", + "The mass was located on the posterior aspect of the popliteal fossa.", + "Local ultrasonography showed evidence of a heterogeneous hypoechoic lesion with signs of inflammation.", + "Underlying bony cortices appeared to be normal.", + "A clinical diagnosis of Baker's cyst was made.", + "An excisional biopsy was performed.", + "Microscopically, histologic sections showed fibroblasts arranged in loose fascicular patterns.", + "The histologic sections showed fibroblasts intermixed with a small amount of collagen and myxoid stroma." + ] + }, + { + "id": "multiclinsum_test_718_en.txt", + "fulltext": "A 97-year-old Caucasian woman presented to the emergency department of our institution with a painful, malodorous, necrotic right submandibular mass . A solitary enlarged lymph node had been identified in this region on computed tomography two months prior. She gave no history of B-symptoms, immunodeficiency or immunosuppression.\nShe lived at home alone with support from a carer who visited twice daily. She did not smoke tobacco or consume alcohol. Her comorbidities included dementia, congestive cardiac failure, paroxysmal atrial fibrillation, a previous above-knee deep vein thrombosis and early-stage breast cancer diagnosed 17 years earlier, managed surgically and considered to be in remission. Her regular medications included bisoprolol 2.5 mg daily, ramipril 1.25 mg daily, aspirin 100 mg daily, digoxin 62.5 μg daily and periciazine 2.5 mg daily.\nShe was afebrile and hemodynamically normal at presentation and other than the right neck mass, her physical examination was unremarkable. Blood work showed a white cell count of 10.87 × 109/L (normal range, 4–11) with slight neutrophilia at 9.05 × 109/L (normal range, 1.8–7.5) and lymphopenia at 1.01 × 109/L (normal range, 1.5–3.5). Her hemoglobin was normal at 137 g/L, as was her platelet count of 197 × 109/L. Her potassium was measured as 3.3 mmol/L (normal range, 3.5–4.9) but all other electrolytes were within the normal range. Her creatinine measured 69 μmol/L with an estimated glomerular filtration rate of 64 ml/minute/1.73 m2. Her lactate dehydrogenase was elevated at 267 U/L (normal range, 110–230) but her liver enzymes were all within the normal range.\nFollowing non-diagnostic fine needle aspiration of the mass, core biopsy revealed DLBCL with a non-germinal center immunophenotype using the Han's algorithm, and Epstein Barr encoded ribonucleic acid (RNA) in situ hybridization positivity .\nComputed tomography and 18-fluorodeoxyglucose (FDG) positron emission tomography revealed this to be the only site of disease, consistent with stage 1A.\nGiven her age, frailty, performance status and multiple comorbidities, she was deemed unfit for systemic therapy and palliative radiotherapy was recommended.\nShe received a dose of 25 Gy delivered over five fractions on alternate days over a two-week period. Treatment was delivered using a four-beam three-dimensional conformal technique with 6-megavoltage photons and daily image guidance. The treatment incorporated the use of bolus material placed over the surface of the mass to optimize the radiation dose delivered superficially to the skin.\nThe patient was followed up monthly and after four months the mass completely resolved . The overlying skin on the right neck had healed to cover the previous necrotic deficit and no mass was palpable. She was asymptomatic with no observable toxicity at the latest review at four months.", + "fulltext_subclaims": [ + "The patient is a 97-year-old Caucasian woman.", + "She presented with a painful, malodorous, necrotic right submandibular mass.", + "A solitary enlarged lymph node had been identified in this region on computed tomography two months prior.", + "She gave no history of B-symptoms.", + "She gave no history of immunodeficiency.", + "She gave no history of immunosuppression.", + "She lived at home alone with support from a carer who visited twice daily.", + "She did not smoke tobacco.", + "She did not consume alcohol.", + "Her comorbidities included dementia.", + "Her comorbidities included congestive cardiac failure.", + "Her comorbidities included paroxysmal atrial fibrillation.", + "Her comorbidities included a previous above-knee deep vein thrombosis.", + "Her comorbidities included early-stage breast cancer diagnosed 17 years earlier.", + "The breast cancer was managed surgically.", + "The breast cancer was considered to be in remission.", + "Her regular medications included bisoprolol 2.5 mg daily.", + "Her regular medications included ramipril 1.25 mg daily.", + "Her regular medications included aspirin 100 mg daily.", + "Her regular medications included digoxin 62.5 μg daily.", + "Her regular medications included periciazine 2.5 mg daily.", + "She was afebrile at presentation.", + "She was hemodynamically normal at presentation.", + "Her physical examination was unremarkable other than the right neck mass.", + "Her white cell count was 10.87 × 109/L.", + "Her neutrophil count was 9.05 × 109/L.", + "Her lymphocyte count was 1.01 × 109/L.", + "Her hemoglobin was 137 g/L.", + "Her platelet count was 197 × 109/L.", + "Her potassium was 3.3 mmol/L.", + "Her creatinine was 69 μmol/L.", + "Her estimated glomerular filtration rate was 64 ml/minute/1.73 m2.", + "Her lactate dehydrogenase was 267 U/L.", + "Fine needle aspiration of the mass was non-diagnostic.", + "Core biopsy revealed DLBCL.", + "The DLBCL had a non-germinal center immunophenotype using the Han's algorithm.", + "Epstein Barr encoded ribonucleic acid (RNA) in situ hybridization was positive.", + "Computed tomography and 18-fluorodeoxyglucose (FDG) positron emission tomography revealed this to be the only site of disease.", + "The disease was consistent with stage 1A.", + "She was deemed unfit for systemic therapy.", + "Palliative radiotherapy was recommended.", + "She received a dose of 25 Gy delivered over five fractions.", + "Treatment was delivered using a four-beam three-dimensional conformal technique.", + "The treatment incorporated the use of bolus material placed over the surface of the mass.", + "The patient was followed up monthly.", + "After four months, the mass completely resolved.", + "The overlying skin on the right neck had healed to cover the previous necrotic deficit.", + "No mass was palpable at four months.", + "She was asymptomatic at four months.", + "No observable toxicity was noted at four months." + ], + "summary": "A 97-year-old Caucasian woman presented to the emergency department of our institution with a painful, malodorous, necrotic right upper neck mass, which had progressed over a two-month period. Investigations confirmed stage 1A diffuse large B-cell lymphoma. Palliative radiotherapy was delivered to a dose of 25 Gray (Gy) in five fractions on alternate days over two consecutive weeks. After four months, the mass completely resolved with no residual symptoms.", + "summary_subclaims": [ + "The patient is a 97-year-old Caucasian woman.", + "She presented with a painful, malodorous, necrotic right upper neck mass.", + "The mass had progressed over a two-month period.", + "Investigations confirmed stage 1A diffuse large B-cell lymphoma.", + "Palliative radiotherapy was delivered to a dose of 25 Gray (Gy) in five fractions.", + "The radiotherapy was delivered on alternate days over two consecutive weeks.", + "After four months, the mass completely resolved.", + "There were no residual symptoms." + ] + }, + { + "id": "multiclinsum_test_1824_en.txt", + "fulltext": "A 21-year-old male college student presented with no previous medical history or any drug intake. During a tackle at rugby practice, his forehead collided with the forehead of an opponent. Immediately after the collision remained asymptomatic and continued to play. However, several hours later of the same day, the patient started experiencing a mild headache with a gnawing pain all over the head. On the 2nd day, he took part in another rugby practice. However, during the rugby practice, experienced several episodes of transient left lower extremity paralysis reporting the event to the team trainer that suspected a concussion and immediately ordered him to stop playing. On the 3rd day of illness, he reported to the team doctor, who instructed him to visit our hospital.\nThe patient did not have headache or posterior neck pain. His Glasgow coma scale score was 4-5-6 and he did not have pupillary abnormalities, nystagmus, eye movement disorder, tetraplegia, sensory disturbance, or balance disorder. The finger-nose test did not reveal any abnormality in the patient. Similarly, his blood tests showed no abnormalities. His electrocardiogram showed sinus rhythm and a pulse rate of 56/min.\nComputed tomography of the head did not show intracranial hemorrhage, but low absorptive changes were observed in the medial right frontal lobe. Magnetic resonance angiography (MRA) showed occlusion of the right ACA. T1-VISTA revealed an intramural hematoma (hyperintense intramural signal) that was consistent with the occluded artery [ and ]. Carotid artery echocardiography showed no abnormality. Based on the above-mentioned results, the patient was diagnosed with acute cerebral infarction due to traumatic ACA dissection.\nHe was admitted urgently on the 3rd day of illness and underwent thorough neurological examination and blood pressure monitoring. Since the CVI was caused by dissection, there is a possibility that an aneurysm may form in the future that could cause a cerebral hemorrhage. Therefore, the patient was not administered antithrombotic therapy. After admission, the patient was closely monitored for blood pressure, which was not high enough to require antihypertensive medication. He remained clear and conscious with no recurrence of headache or lower extremity paralysis. It was decided to evaluate his vessel with a minimally invasive MRI. If the MRI showed cerebral infarct enlargement or aneurysm formation, a digital subtraction angiography (DSA) was scheduled for a more detailed evaluation. T1-VISTA was repeated on the 10th illness day; it did not show recanalization of the occluded artery and no aneurysm had formed . On the 11th day of illness, he was discharged home with a modified Rankin scale score of 0. After discharge, he underwent a follow-up MRI.\nT1-VISTA performed 1 month after the SRHI (i.e., on the 31st day of illness) showed recanalization of the occluded artery, but no aneurysmal changes were observed . In addition, the intramural hematoma had extended to the periphery of the artery. T1-VISTA performed 3 months after the SRHI (i.e., on the 82nd day of illness) showed maintained recanalization, but it did not show aneurysm formation or any other morphological abnormality of the artery. It also showed that the size of the intramural hematoma had decreased .\nOur plan was to perform DSA if there were any changes in vessel morphology over time and to consider the need for additional treatment. In this case, he was able to be followed the changes in vascular morphology using MRI and T1-VISTA. Based on the above clinical and radiological course, we decided that the patient would continue to be followed conservatively and that detailed examination with DSA was unnecessary.", + "fulltext_subclaims": [ + "The patient is a 21-year-old male college student.", + "The patient had no previous medical history.", + "The patient had no drug intake.", + "During a tackle at rugby practice, his forehead collided with the forehead of an opponent.", + "Immediately after the collision, the patient remained asymptomatic.", + "The patient continued to play after the collision.", + "Several hours after the collision, the patient started experiencing a mild headache with a gnawing pain all over the head.", + "On the 2nd day, the patient took part in another rugby practice.", + "During the rugby practice, the patient experienced several episodes of transient left lower extremity paralysis.", + "The team trainer suspected a concussion.", + "The team trainer ordered the patient to stop playing.", + "On the 3rd day of illness, the patient reported to the team doctor.", + "The team doctor instructed the patient to visit the hospital.", + "The patient did not have headache or posterior neck pain.", + "The Glasgow coma scale score was 4-5-6.", + "The patient did not have pupillary abnormalities.", + "The patient did not have nystagmus.", + "The patient did not have eye movement disorder.", + "The patient did not have tetraplegia.", + "The patient did not have sensory disturbance.", + "The patient did not have balance disorder.", + "The finger-nose test did not reveal any abnormality.", + "Blood tests showed no abnormalities.", + "The electrocardiogram showed sinus rhythm.", + "The electrocardiogram showed a pulse rate of 56/min.", + "Computed tomography of the head did not show intracranial hemorrhage.", + "Low absorptive changes were observed in the medial right frontal lobe.", + "Magnetic resonance angiography showed occlusion of the right ACA.", + "T1-VISTA revealed an intramural hematoma (hyperintense intramural signal) that was consistent with the occluded artery.", + "Carotid artery echocardiography showed no abnormality.", + "The patient was diagnosed with acute cerebral infarction due to traumatic ACA dissection.", + "The patient was admitted urgently on the 3rd day of illness.", + "The patient underwent a thorough neurological examination.", + "The patient underwent blood pressure monitoring.", + "Since the CVI was caused by dissection, there is a possibility that an aneurysm may form in the future that could cause a cerebral hemorrhage.", + "The patient was not administered antithrombotic therapy.", + "After admission, the patient was closely monitored for blood pressure.", + "The patient's blood pressure was not high enough to require antihypertensive medication.", + "The patient remained clear and conscious.", + "The patient did not have recurrence of headache.", + "The patient did not have recurrence of lower extremity paralysis.", + "It was decided to evaluate the vessel with a minimally invasive MRI.", + "If the MRI showed cerebral infarct enlargement or aneurysm formation, a digital subtraction angiography was scheduled.", + "T1-VISTA was repeated on the 10th day of illness.", + "T1-VISTA did not show recanalization of the occluded artery.", + "T1-VISTA did not show aneurysm formation.", + "The patient was discharged home on the 11th day of illness.", + "The patient had a modified Rankin scale score of 0.", + "After discharge, the patient underwent a follow-up MRI.", + "T1-VISTA performed 1 month after the SRHI showed recanalization of the occluded artery.", + "T1-VISTA performed 1 month after the SRHI did not show aneurysmal changes.", + "The intramural hematoma had extended to the periphery of the artery.", + "T1-VISTA performed 3 months after the SRHI showed maintained recanalization.", + "T1-VISTA performed 3 months after the SRHI did not show aneurysm formation.", + "T1-VISTA performed 3 months after the SRHI did not show any other morphological abnormality of the artery.", + "The size of the intramural hematoma had decreased.", + "Our plan was to perform DSA if there were any changes in vessel morphology over time.", + "Our plan was to consider the need for additional treatment.", + "In this case, the patient was able to be followed the changes in vascular morphology using MRI and T1-VISTA.", + "Based on the clinical and radiological course, we decided that the patient would continue to be followed conservatively.", + "Based on the clinical and radiological course, we decided that detailed examination with DSA was unnecessary." + ], + "summary": "The patient was a 21-year-old man. During a rugby tackle, his forehead collided with the forehead of an opponent. He did not have a headache or disturbance of consciousness immediately after the SRHI. On the 2nd day of illness, he had transient weakness of the left lower limb several times. On the 3rd day of illness, he visited our hospital. MRI revealed occlusion of the right ACA and acute infarction of the right medial frontal lobe. T1-VISTA revealed intramural hematoma of the occluded artery. He was diagnosed with acute cerebral infarction due to dissection of the ACA and was followed up for vascular changes with T1-VISTA. The vessel had recanalized and the size of the intramural hematoma had decreased 1 and 3 months after the SRHI, respectively.", + "summary_subclaims": [ + "The patient was a 21-year-old man.", + "During a rugby tackle, his forehead collided with the forehead of an opponent.", + "He did not have a headache or disturbance of consciousness immediately after the SRHI.", + "On the 2nd day of illness, he had transient weakness of the left lower limb several times.", + "On the 3rd day of illness, he visited our hospital.", + "MRI revealed occlusion of the right ACA and acute infarction of the right medial frontal lobe.", + "T1-VISTA revealed intramural hematoma of the occluded artery.", + "He was diagnosed with acute cerebral infarction due to dissection of the ACA.", + "He was followed up for vascular changes with T1-VISTA.", + "The vessel had recanalized 1 month after the SRHI.", + "The size of the intramural hematoma had decreased 3 months after the SRHI." + ] + }, + { + "id": "multiclinsum_test_3255_en.txt", + "fulltext": "45-year-old woman with a medical history of hypertension and a surgical history of a video-laparoscopic cholecystectomy 6 years ago. She was admitted to our department due to a 3-month evolution of a condition characterised by digestive intolerance associated with a 10 kg weight loss. The laboratory presented a leukocytosis (GB: 25170/uL) as the only relevant data. A tumour marker assay (CEA and CA19-9) was performed, which was normal. A tomography of the chest, abdomen and pelvis was performed with intravenous contrast, where a relevant finding was observed at the gastrointestinal level, gastric distension with thickening of the mucosa with a sclerosing appearance at the level of the pyloric region. It was completed with a high-definition upper gastrointestinal endoscopy, which detected a mucous lesion that was raised, totally obstructive, friable, and indurated, from which multiple biopsies were taken. The result of the pathological anatomy reported a mucous duodenal infiltrated by carcinoma with a squamous differentiation. Techniques of immunohistochemistry (IHC) were performed, which interpreted the diagnosis as a poorly differentiated pavement carcinoma, and it was not possible to define the primary site of origin, since all pavement carcinomas have a similar immunophenotype, regardless of their anatomical origin. As a complementary method, a positron emission tomography (PET-CT) was requested, which reported a solid hypermetabolic lesion in the topography of the second portion of the duodenum, in close relationship, without a cleavage plane, with the head of the pancreas, 31 x 32 mm in diameter, and presented a SUVmax of 17.7. The lesion caused a supra-stenotic dilation of the digestive tract. The patient was evaluated by specialists in gynaecology, head and neck surgery and thoracic surgery, seeking, in the first instance, to ensure that the pancreatic tumour was not a metastasis of another origin. Based on the findings, a surgical procedure was defined and a duodenopancreatectomy was performed. The pathological anatomy reported a poorly differentiated, infiltrating carcinoma of pancreatic origin that compromised the duodenum, with a maximum tumour size of 4 cm. A neoplastic proliferation with dyskeratic areas and central necrosis was observed in the pancreatic stroma, data compatible with neoplastic squamous cells. To confirm the cell line, an IHC of the surgical piece was requested, which reported the presence of AE1/AE3, cytokeratin 5 and P 63 positive, compatible with a primary pancreatic squamous carcinoma. The patient evolved without complications from her surgery. She was presented to an interdisciplinary oncological committee, where the performance of adjuvant treatment with CAPOX (capecitabine and oxaliplatin) was defined. Currently, 24 months after the postoperative, she is free of disease with periodic checks. The patient signed the corresponding informed consent and the ethics committee was informed for the publication of the case.\n", + "fulltext_subclaims": [ + "The patient is a 45-year-old woman.", + "She has a medical history of hypertension.", + "She had a video-laparoscopic cholecystectomy 6 years ago.", + "She was admitted due to a 3-month evolution of a condition characterised by digestive intolerance.", + "She had a 10 kg weight loss.", + "The laboratory showed a leukocytosis (GB: 25170/uL).", + "A tomography of the chest, abdomen and pelvis was performed with intravenous contrast.", + "The tomography showed gastric distension with thickening of the mucosa with a sclerosing appearance at the level of the pyloric region.", + "A high-definition upper gastrointestinal endoscopy was performed.", + "The endoscopy detected a mucous lesion that was raised, totally obstructive, friable, and indurated.", + "Multiple biopsies were taken.", + "The pathological anatomy reported a mucous duodenal infiltrated by carcinoma with a squamous differentiation.", + "Immunohistochemistry was performed.", + "The diagnosis was interpreted as a poorly differentiated pavement carcinoma.", + "It was not possible to define the primary site of origin.", + "A positron emission tomography (PET-CT) was requested.", + "The PET-CT reported a solid hypermetabolic lesion in the topography of the second portion of the duodenum.", + "The lesion was in close relationship, without a cleavage plane, with the head of the pancreas.", + "The lesion was 31 x 32 mm in diameter.", + "The lesion had a SUVmax of 17.7.", + "The lesion caused a supra-stenotic dilation of the digestive tract.", + "The patient was evaluated by specialists in gynaecology, head and neck surgery and thoracic surgery.", + "A duodenopancreatectomy was performed.", + "The pathological anatomy reported a poorly differentiated, infiltrating carcinoma of pancreatic origin that compromised the duodenum.", + "The maximum tumour size was 4 cm.", + "An IHC of the surgical piece was requested.", + "The IHC reported the presence of AE1/AE3, cytokeratin 5 and P 63 positive.", + "The diagnosis was compatible with a primary pancreatic squamous carcinoma.", + "The patient evolved without complications from her surgery.", + "Adjuvant treatment with CAPOX (capecitabine and oxaliplatin) was defined.", + "Currently, 24 months after the postoperative, she is free of disease.", + "The patient signed the corresponding informed consent.", + "The ethics committee was informed for the publication of the case." + ], + "summary": "A 45-year-old woman presented with a history of digestive intolerance and weight loss of 10 kg over three months. Studies confirmed a tumour in the head of the pancreas that was compressing the second duodenal portion. A duodenopancreatectomy was performed and a primary squamous carcinoma of the pancreas was found and confirmed by pathological anatomy.\n", + "summary_subclaims": [ + "The patient is a 45-year-old woman.", + "The patient had a history of digestive intolerance.", + "The patient had weight loss of 10 kg over three months.", + "Studies confirmed a tumour in the head of the pancreas.", + "The tumour was compressing the second duodenal portion.", + "A duodenopancreatectomy was performed.", + "A primary squamous carcinoma of the pancreas was found.", + "The diagnosis was confirmed by pathological anatomy." + ] + }, + { + "id": "multiclinsum_test_2650_en.txt", + "fulltext": "A 14-year-old White Italian boy came to our Emergency Unit with a headache that had worsened over 20 days together with blurred vision and diplopia over the previous 10 days. His past history was negative for significant morbidities. He reported a recent episode of fever associated with cough, which coincided with the onset of headache. For this respiratory infection he had started taking levofloxacin 500 mg once a day one week before coming to our attention but had stopped taking it after three days due to worsening headache. This headache was initially associated with daytime somnolence, myalgia and arthralgia. The somnolence and arthralgia underwent rapid and spontaneous regression, with subsequent appearance of blurred vision.\nThe physical examination revealed an alert adolescent with weight of 66 kg (75th -90th percentile) , height of 169 cm (50th–75th percentile) and body mass (BMI) of 23.1 kg/m2 (85th–95th percentile) . The general examination was normal. The neurological examination was normal except for a right eye abduction deficit. Eye examination showed a normal visual acuity (10/10) in both eyes with normal colour vision and pupillary light responses, but a fundus examination revealed severe bilateral papilloedema with elevated disc, hyperaemia, blurred margins and vessel tortuosity in both eyes . Lancaster red-green test confirmed a right abducens nerve palsy, and campimetry showed a restricted visual field with external right muscle deficiency on the right side. Cranial neuroimaging (CT and MRI) showed a normal brain parenchyma with no evidence of hydrocephalus, mass, structural lesion, or abnormal meningeal enhancement. MRI neuroimaging showed oedema of both optic nerves with a tapered appearance of the right optic nerve. Venography was not performed, but an angio-MRI of the cerebral circulation was normal. Visual evoked cortical potentials were normal. A 24-h Ambulatory Blood Pressure Monitoring was negative.\nBlood tests showed high M. pneumoniae IgM (15.00 AU/ml, normal range 0–9) and normal M. pneumoniae IgG levels (3.89 AU/ml, normal range 0–9) suggesting a recent infection, with normal white blood cell indices and negative C-reactive protein. Clarithromycin was then prescribed for 14 days without any adverse effects.\nSerological screening for Coxsackie, Parvovirus, ECHO virus, Adenovirus, Cytomegalovirus (CMV), Epstein-Barr Virus (EBV), Herpes Simplex Virus 1 (HSV1), and Herpes Simplex Virus 2 (HSV2) excluded recent infections. Thyroid function was normal. Antinuclear antibodies (ANA), anti-double stranded DNA (dsDNA), ENA screening and rheumatoid factor were negative.\nDuring hospitalisation we observed a complete and spontaneous regression of headache and an initial spontaneous reduction in diplopia within a few days. Oral prednisone 50 mg/day (0.75 mg/kg/day) was administered for a week and ocular fundus was monitored.\nSince severe bilateral papilloedema persisted one week after the first assessment, lumbar puncture was performed with the patient sedated and relaxed in lateral recumbent position. Opening cerebrospinal fluid (CSF) pressure measured with a standard manometer was 20 cm H2O and closing pressure was 19 cm H2O. These CSF pressure values have traditionally been considered borderline, but are within normal range according to a recent study in children .\nCSF biochemical tests and cultures were negative. HSV1, HSV2, VZV, HHV6, CMV, Neisseria, Haemophilus, Streptococcus pneumoniae, Streptococcus B group, Escherichia coli, Listeria and Cryptococcus neoformans, Parvovirus, Adenovirus, EBV DNA and Enterovirus and Parechovirus RNA PCR were negative. CSF oligoclonal bands were absent on CSF and blood tests.\nOral acetazolamide (1 g divided twice daily) was introduced to accelerate recovery. A gradual further improvement in diplopia was seen during hospitalisation . Ophthalmological, neurological and neurosurgical follow up was continued after discharge. The patient gradually improved, with complete resolution of the right abducens nerve palsy in one month and resolution of papilloedema in three months . For this reason, acetazolamide was gradually reduced and stopped on resolution of the papilloedema (see Additional file ).", + "fulltext_subclaims": [ + "The patient is a 14-year-old White Italian boy.", + "He came to the Emergency Unit with a headache that had worsened over 20 days.", + "He had blurred vision and diplopia over the previous 10 days.", + "He reported a recent episode of fever associated with cough.", + "He had started taking levofloxacin 500 mg once a day one week before coming to the hospital.", + "He had stopped taking levofloxacin after three days due to worsening headache.", + "The headache was initially associated with daytime somnolence, myalgia, and arthralgia.", + "The somnolence and arthralgia underwent rapid and spontaneous regression.", + "The physical examination revealed a right eye abduction deficit.", + "The eye examination showed a normal visual acuity (10/10) in both eyes.", + "Fundus examination revealed severe bilateral papilloedema.", + "Lancaster red-green test confirmed a right abducens nerve palsy.", + "Cranial neuroimaging showed no evidence of hydrocephalus, mass, structural lesion, or abnormal meningeal enhancement.", + "MRI showed oedema of both optic nerves.", + "Venography was not performed.", + "Blood tests showed high M. pneumoniae IgM (15.00 AU/ml).", + "Serological screening excluded recent infections with Coxsackie, Parvovirus, ECHO virus, Adenovirus, CMV, EBV, HSV1, and HSV2.", + "During hospitalisation, there was a complete and spontaneous regression of headache.", + "Oral prednisone 50 mg/day was administered for a week.", + "Lumbar puncture was performed with the patient sedated and relaxed in lateral recumbent position.", + "Opening cerebrospinal fluid pressure was 20 cm H2O.", + "CSF biochemical tests and cultures were negative.", + "Oral acetazolamide (1 g divided twice daily) was introduced.", + "The patient gradually improved with complete resolution of the right abducens nerve palsy in one month.", + "The papilloedema resolved in three months." + ], + "summary": "We report on a 14-year-old overweight White Italian boy who suffered headache, diplopia, and severe bilateral papilloedema after a Mycoplasma pneumoniae infection, exacerbated on levofloxacin intake. A spontaneous improvement in headache and a reduction in diplopia was seen during hospitalisation. Oral acetazolamide therapy led to the regression of papilloedema in about five months. No permanent eye damage has been observed in our patient to date.", + "summary_subclaims": [ + "The patient is a 14-year-old overweight White Italian boy.", + "The patient suffered headache.", + "The patient suffered diplopia.", + "The patient had severe bilateral papilloedema.", + "The symptoms occurred after a Mycoplasma pneumoniae infection.", + "The symptoms were exacerbated on levofloxacin intake.", + "A spontaneous improvement in headache was seen during hospitalisation.", + "A reduction in diplopia was seen during hospitalisation.", + "Oral acetazolamide therapy led to the regression of papilloedema in about five months.", + "No permanent eye damage has been observed in our patient to date." + ] + }, + { + "id": "multiclinsum_test_1534_en.txt", + "fulltext": "Following a motor vehicle accident, a 25-year-old female complained of intense neck pain, but remained neurologically intact. The lateral cervical radiograph showed an oblique fracture of the axis; the fracture diagonally separated the vertebra in two parts and extended from the body of the axis to the posterior elements. In addition, the computed tomography (CT) scan revealed several craniovertebral junction (CVJ) anomalies, which included spontaneous KFS fusion of the C2-C3 disc space and the C2-C3 right articular facets/laminae. Furthermore, the anterior C1-arch was bifid and there was a partial agenesis of the posterior C1 arch [Figure –]. Following immobilization in a halo vest for 3 months, the fracture fused, maintaining adequate alignment . When contacted by phone 2 years later, she was asymptomatic.", + "fulltext_subclaims": [ + "The patient is a 25-year-old female.", + "The patient complained of intense neck pain.", + "The patient remained neurologically intact.", + "The lateral cervical radiograph showed an oblique fracture of the axis.", + "The fracture diagonally separated the vertebra in two parts.", + "The fracture extended from the body of the axis to the posterior elements.", + "The CT scan revealed several craniovertebral junction (CVJ) anomalies.", + "The CVJ anomalies included spontaneous KFS fusion of the C2-C3 disc space.", + "The CVJ anomalies included the C2-C3 right articular facets/laminae.", + "The anterior C1-arch was bifid.", + "There was a partial agenesis of the posterior C1 arch.", + "The fracture fused after immobilization in a halo vest for 3 months.", + "The fracture maintained adequate alignment.", + "When contacted by phone 2 years later, she was asymptomatic." + ], + "summary": "Following a motor vehicle accident, a 25-year-old female's radiographic studies showed an oblique axis fracture involving both the anterior and posterior elements along with an anterior and posterior Klippel-Feil syndrome (KFS) anomaly. Following treatment in a halo vest, the patient maintained alignment, and ultimately the fracture was fused.", + "summary_subclaims": [ + "The patient is a 25-year-old female.", + "The patient had a motor vehicle accident.", + "Radiographic studies showed an oblique axis fracture.", + "The fracture involved both the anterior and posterior elements.", + "The patient had an anterior and posterior Klippel-Feil syndrome anomaly.", + "The patient was treated in a halo vest.", + "The patient maintained alignment following treatment.", + "The fracture was fused." + ] + }, + { + "id": "multiclinsum_test_966_en.txt", + "fulltext": "A 74-year-old Japanese woman presented with a 6-month history of gradually worsening dyspnea on exertion, a 10-year history of bronchiectasis, a 4-year history of infection with Mycobacterium avium complex, and pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma in remission that had been treated by surgical resection of the right lower lobe and subsequent chemotherapy with single-agent rituximab. She had no history of recurrent epistaxis, and her family history did not include hereditary hemorrhagic telangiectasia (HHT) or PAVMs. She was admitted with pneumonia, symptoms of which were only partially resolved by antibiotic therapy as dyspnea on exertion persisted.\nOverall, physical examination findings were unremarkable. Her lungs were clear to auscultation, and clubbing or evidence of telangiectatic lesions on the nasal mucosa or skin was absent. Blood findings revealed C-reactive protein of 0.32 mg/dL and an erythrocyte sedimentation rate of 50 mm/hour. Arterial blood gas analysis showed slight hypoxemia (PaO2 of 65.9 mmHg on ambient air). Chest radiography showed increased density in the lower lung. Chest computed tomography (CT) showed bronchiectasis and increased density in the right middle lobe and the lingular segment of the left lung. Contrast-enhanced chest CT showed no evidence of pulmonary thromboembolism, but the pulmonary veins of the right middle lobe and left lingular segment were enhanced in the arterial phase. Reconstructed 3D-CECT images revealed abnormal intrapulmonary shunts in the right and left pulmonary arteries and veins. Echocardiography findings did not indicate vascular heart disease. Measuring PaO2 and SaO2 after breathing 100% oxygen for 20 minutes revealed a shunt fraction of 22%. Whole-body 99mTc-macroaggregated albumin (MAA) perfusion lung imaging revealed a shunt fraction of 21.3%. Head magnetic resonance imaging (MRI) findings were normal.\nPulmonary angiography revealed irregular staining of the pulmonary arteries in the right middle lobe and the pulmonary vein during the early phase . Although the typical sac and nidus of PAVMs were not evident, an abnormal shunt was suspected and treated by transcatheter coil embolization. Thereafter, the vein in the early phase was undetectable . The shunt fraction decreased to 12.4%, on 99mTc-MAA lung perfusion images, and the dyspnea on exertion was ameliorated, so the patient was discharged. However, pneumonia reoccurred 3 months later and was improved with antibiotics, but hypoxemia persisted. The shunt fraction on 99mTc-MAA lung perfusion images was elevated to 16%, indicating recanalization of the embolized shunts. Pulmonary angiography did not reveal evidence of recanalization, but new abnormal shunt lesions were found in the periphery of another area of the right middle lobe and in the left lingular segment . The hypoxemia and dyspnea improved after coil embolization of these new lesions, and the patient was discharged. She has remained free of shunt recurrence and is presently under follow-up as an outpatient.", + "fulltext_subclaims": [ + "The patient is a 74-year-old Japanese woman.", + "She had a 10-year history of bronchiectasis.", + "She had a 4-year history of infection with Mycobacterium avium complex.", + "She had pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma in remission.", + "The MALT lymphoma had been treated by surgical resection of the right lower lobe.", + "The MALT lymphoma had been treated by subsequent chemotherapy with single-agent rituximab.", + "She had no history of recurrent epistaxis.", + "Her family history did not include hereditary hemorrhagic telangiectasia (HHT).", + "Her family history did not include PAVMs.", + "She was admitted with pneumonia.", + "Her symptoms were only partially resolved by antibiotic therapy.", + "Dyspnea on exertion persisted.", + "Physical examination findings were unremarkable.", + "Clubbing was absent.", + "Evidence of telangiectatic lesions on the nasal mucosa or skin was absent.", + "C-reactive protein was 0.32 mg/dL.", + "Erythrocyte sedimentation rate was 50 mm/hour.", + "Arterial blood gas analysis showed PaO2 of 65.9 mmHg on ambient air.", + "Chest radiography showed increased density in the lower lung.", + "Chest CT showed bronchiectasis.", + "Chest CT showed increased density in the right middle lobe.", + "Chest CT showed increased density in the lingular segment of the left lung.", + "Contrast-enhanced chest CT showed no evidence of pulmonary thromboembolism.", + "The pulmonary veins of the right middle lobe were enhanced in the arterial phase.", + "The pulmonary veins of the left lingular segment were enhanced in the arterial phase.", + "Reconstructed 3D-CECT images revealed abnormal intrapulmonary shunts in the right and left pulmonary arteries and veins.", + "Echocardiography findings did not indicate vascular heart disease.", + "Measuring PaO2 and SaO2 after breathing 100% oxygen for 20 minutes revealed a shunt fraction of 22%.", + "Whole-body 99mTc-macroaggregated albumin (MAA) perfusion lung imaging revealed a shunt fraction of 21.3%.", + "Head MRI findings were normal.", + "Pulmonary angiography revealed irregular staining of the pulmonary arteries in the right middle lobe.", + "Pulmonary angiography revealed irregular staining of the pulmonary vein during the early phase.", + "The typical sac and nidus of PAVMs were not evident.", + "An abnormal shunt was suspected.", + "The suspected shunt was treated by transcatheter coil embolization.", + "The vein in the early phase was undetectable after embolization.", + "The shunt fraction decreased to 12.4% on 99mTc-MAA lung perfusion images.", + "Dyspnea on exertion was ameliorated.", + "The patient was discharged.", + "Pneumonia reoccurred 3 months later.", + "Pneumonia was improved with antibiotics.", + "Hypoxemia persisted.", + "The shunt fraction on 99mTc-MAA lung perfusion images was elevated to 16%.", + "The elevated shunt fraction indicated recanalization of the embolized shunts.", + "Pulmonary angiography did not reveal evidence of recanalization.", + "New abnormal shunt lesions were found in the periphery of another area of the right middle lobe.", + "New abnormal shunt lesions were found in the left lingular segment.", + "The hypoxemia and dyspnea improved after coil embolization of these new lesions.", + "The patient was discharged.", + "She has remained free of shunt recurrence.", + "She is presently under follow-up as an outpatient." + ], + "summary": "A 74-year-old Japanese woman with a history of bronchiectasis was admitted to our hospital because of dyspnea on exertion. Pulmonary angiography and reconstructed three-dimensional contrast-enhanced computed tomography images showed shunts between pulmonary arteries and pulmonary veins, indicating a diagnosis of pulmonary arteriovenous malformations. Coil embolization of the shunts was successful.", + "summary_subclaims": [ + "The patient is a 74-year-old Japanese woman.", + "The patient has a history of bronchiectasis.", + "The patient was admitted to our hospital because of dyspnea on exertion.", + "Pulmonary angiography showed shunts between pulmonary arteries and pulmonary veins.", + "Reconstructed three-dimensional contrast-enhanced computed tomography images showed shunts between pulmonary arteries and pulmonary veins.", + "The diagnosis was pulmonary arteriovenous malformations.", + "Coil embolization of the shunts was successful." + ] + }, + { + "id": "multiclinsum_test_2441_en.txt", + "fulltext": "We report on a 33 year-old male patient followed at our center for a unrepaired tricuspid atresia type IC with unrestricted ventricular septal defect with left-right shunting, a non-restricted atrial septal defect with right-left shunting, and a functional single left ventricle with normal systolic function . His past medical history included two attempts of pulmonary artery banding at the age of 15 and 19 years at initial presentation at our center, requiring subsequent debanding due to ventricular arrhythmia. The patient declined any further surgical interventions and developed pulmonary arterial hypertension (PAH) class I.4.4. according to the Nice classification , with a pulmonary resistance of 7.5 WU and a persisting significant left to right shunt (Qp:Qs = 2.5 :1). Oxygen saturation at room air was 86 %. The patient is also known for cardiac cachexia, asthma without allergic components, and a restrictive syndrome of extra-pulmonary origin (mainly due to scoliosis and post-thoracotomy status). He developed secondary erythrocytosis and suffered a single episode of vertebrobasilar transient ischemic attack (TIA) in 2010, presumably of embolic origin. Anticoagulation with acenocoumarol was started. In 2016, he experienced a first episode of paroxysmal tachycardic atrial fibrillation (AFib) requiring emergency electric cardioversion. At that time, therapy with amiodarone and metoprolol was initiated and anticoagulation changed to apixaban 2.5 mg bid. In 2018, a second episode of tachycardic Afib associated with hemodynamic instability required an urgent electrical cardioversion. While he was euthyroid in the past, thyroid function tests performed in fall 2019 documented overt thyrotoxicosis with a TSH of < 0.005 mUI/l (0.27–4.3), a FT4 of 64 pmol/l (9–19), and a free T3 of 10.4 pmol/l (2.6–5.7) (Abbbott Architect immunometric assays). Antibodies against the TSH receptor were not elevated (0.51 U/l; reference <1.75) A thyroid ultrasound showed a goiter without nodules and with diminished vascularity. The diagnosis of amiodarone-induced thyrotoxicosis (AIT), most likely of mixed nature, was established and treatment with carbimazole and prednisone initiated. The biochemical control remained unsatisfactory despite therapy with carbimazole 40 mg qd, prednisone 40 mg qd, and sodium perchlorate 900 mg qd. In parallel, the patient had recurrent episodes of tachycardic Afib leading finally to a prolonged hospitalization and a further electric cardioversion. The patient eventually developed persistent Afib which remained tachycardic and symptomatic despite the intensification of antiarrhythmic treatment with amiodarone, nadolol, digoxin and diltiazem.\nDue to the refractoriness of Afib to medical treatment and the evidence of a newly compromised ventricular systolic function, the indication for semi-elective total thyroidectomy was established. Because of the very high anesthesiological risk due to the compromised cardiovascular and pulmonary situation, the indication for a thyroidectomy under local anesthesia was established in a multidisciplinary meeting. Rather than opting for intravenous sedation, it was decided to use hypnosis. All procedural steps were discussed and explained in detail with the patient. In particular, the anaesthesiologist-hypnotherapist provided thorough information about the hypnosis and local anesthesia. This also included a comprehensive collection of personal data of the patient with a focus on memory, observational capacity, understanding, personal activities, environment, and sensorial aspects . The patient provided informed consent and was willing to accept the risks of a general anesthesia in case of conversion to general anesthesia would have been necessary.\nAfter standard monitoring in use in our department, the induction of hypnosis was performed in the operating room. Remifentanil (0.04 mcg/kg/min) was started concomitantly and used throughout the surgery. In order to induce relaxation and calmly modulate perceptions, sensations, and emotions of the patient, permissive suggestions were used by the anaesthesiologist-hypnotherapist. The operating room was prepared accordingly: the anaesthetist's monitoring devices as well as the surgical instruments were silenced, lights were dimmed, staff communicated in soft voice, and access to the room was strictly limited. The patient was placed in a semi-seated position, with his neck in slight hyper-extension. Once the anesthesiologist in charge of hypnosis gave the “go ahead”, the neck was prepared for surgery. As described elsewhere , anaesthesia was applied around the sternocleidomastoid muscle. A line connecting the mastoid process to the clavicle on the anterior and posterior edge of the sternocleidomastoid was drawn . A total of 29 mL of lidocaine 1% with adrenalin was injected on both sides as follows: middle of the posterior margin of the sternocleidomastoid (corresponding to the emergence of the superficial cervical plexus), anteriorly and longitudinally at 3 points (cervical branches), in the muscle itself, and along the cervical incision.\nGiven the multiple cardiac and large vessel malformations, a possible variant of the inferior laryngeal nerve was expected. Intra-operative neuromonitoring was not used. During surgery, a non-recurrent laryngeal nerve on the right side could indeed be identified. Surgery was performed with a harmonic scalpel (Harmonic FOCUS Curved Shear, Ethicon Endo-Surgery) and electro-bipolar forceps. All parathyroid glands were identified and preserved.\nCommunication with the patient was maintained at all times during hypnosis. The patient was then gradually guided back to full consciousness through controlled, focused breathing. Total hypnosis time was 165 min and surgery lasted 100 min.\nIn the recovery room, the patient was completely awakened. The intra- and post-operative pain control were evaluated using a numerical rating scale (0–10). The patient recalled almost no pain during the intervention (1/10), but experienced severe sore throat (8/10) during the first post-operative night and the following day, which improved within 48 h (3/10). During the first night in the intensive care unit, no rhythm disturbances requiring treatment were recorded. He developed transient asymptomatic hypocalcemia (2.0 mmol/L), corrected by oral calcium. The post-operative parathyroid hormone level was normal (35 ng/L).\nIn the immediate post-operative period, the patient complained of extreme fatigue which is a well described consequences of hypnosis .\nThe anatomopathological examination revealed a diffuse goiter (5 × 3.5 × 2.5 on the left side and 6.5 × 3.5 × 2.5 on the right).\nBecause of recurrent Afib, sinus rhythm was restored by a repeat electric cardioversion. The antiarrhythmic therapy with amiodarone, nadolol and diltiazem was continued. At 4 month follow-up, the interrogation of the loop recorder showed maintenance of sinus rhythm and only short runs of Afib.", + "fulltext_subclaims": [ + "The patient is a 33 year-old male.", + "The patient has unrepaired tricuspid atresia type IC.", + "The patient has an unrestricted ventricular septal defect with left-right shunting.", + "The patient has a non-restricted atrial septal defect with right-left shunting.", + "The patient has a functional single left ventricle with normal systolic function.", + "The patient had two attempts of pulmonary artery banding at the age of 15 and 19 years.", + "The patient declined any further surgical interventions.", + "The patient has pulmonary arterial hypertension class I.4.4 according to the Nice classification.", + "The patient's pulmonary resistance is 7.5 WU.", + "The patient has a persisting significant left to right shunt (Qp:Qs = 2.5 :1).", + "The patient's oxygen saturation at room air is 86%.", + "The patient has cardiac cachexia.", + "The patient has asthma without allergic components.", + "The patient has a restrictive syndrome of extra-pulmonary origin.", + "The patient has secondary erythrocytosis.", + "The patient had a single episode of vertebrobasilar transient ischemic attack in 2010.", + "The patient's TIA was presumably of embolic origin.", + "The patient is on anticoagulation with acenocoumarol.", + "The patient had a first episode of paroxysmal tachycardic atrial fibrillation in 2016.", + "The patient required emergency electric cardioversion in 2016.", + "The patient was started on amiodarone and metoprolol in 2016.", + "The patient's anticoagulation was changed to apixaban 2.5 mg bid in 2016.", + "The patient had a second episode of tachycardic Afib in 2018.", + "The patient required urgent electrical cardioversion in 2018.", + "The patient had overt thyrotoxicosis in fall 2019.", + "The patient's TSH was < 0.005 mUI/l in fall 2019.", + "The patient's FT4 was 64 pmol/l in fall 2019.", + "The patient's free T3 was 10.4 pmol/l in fall 2019.", + "The patient's TSH receptor antibodies were not elevated.", + "The patient's thyroid ultrasound showed a goiter without nodules.", + "The diagnosis of amiodarone-induced thyrotoxicosis was established.", + "The patient was treated with carbimazole, prednisone, and sodium perchlorate.", + "The patient had biochemical control that remained unsatisfactory.", + "The patient had recurrent episodes of tachycardic Afib.", + "The patient developed persistent Afib.", + "The patient's Afib remained tachycardic and symptomatic.", + "The indication for semi-elective total thyroidectomy was established.", + "The indication for a thyroidectomy under local anesthesia was established.", + "The patient provided informed consent.", + "The patient was willing to accept the risks of general anesthesia.", + "The induction of hypnosis was performed in the operating room.", + "Remifentanil was started concomitantly and used throughout the surgery.", + "The patient was placed in a semi-seated position.", + "The patient's neck was in slight hyper-extension.", + "A total of 29 mL of lidocaine 1% with adrenalin was injected on both sides.", + "A non-recurrent laryngeal nerve on the right side was identified.", + "All parathyroid glands were identified and preserved.", + "The patient was guided back to full consciousness through controlled, focused breathing.", + "Total hypnosis time was 165 min.", + "Surgery lasted 100 min.", + "The patient recalled almost no pain during the intervention.", + "The patient experienced severe sore throat during the first post-operative night.", + "The patient's sore throat improved within 48 h.", + "The patient developed transient asymptomatic hypocalcemia.", + "The post-operative parathyroid hormone level was normal.", + "The patient complained of extreme fatigue in the immediate post-operative period.", + "The anatomopathological examination revealed a diffuse goiter.", + "Sinus rhythm was restored by a repeat electric cardioversion.", + "The antiarrhythmic therapy with amiodarone, nadolol, and diltiazem was continued.", + "At 4 month follow-up, the interrogation of the loop recorder showed maintenance of sinus rhythm.", + "At 4 month follow-up, the interrogation of the loop recorder showed only short runs of Afib." + ], + "summary": "A 33-year old male patient with cyanotic congenital heart disease due to unrepaired tricuspid atresia type Ic and associated pulmonary arterial hypertension presented with tachycardic atrial fibrillation and amiodarone-induced thyrotoxicosis resulting in recurrent hemodynamic instability. Because of difficulties controlling the thyrotoxic state, the indication for total thyroidectomy was established. Total thyroidectomy was subsequently performed using local anesthesia combined using a hypnosis-analgesia technique instead of intravenous sedation. The intervention and the post-operative course were uneventful.", + "summary_subclaims": [ + "The patient is a 33-year old male.", + "The patient has cyanotic congenital heart disease.", + "The cyanotic congenital heart disease is due to unrepaired tricuspid atresia type Ic.", + "The patient has associated pulmonary arterial hypertension.", + "The patient presented with tachycardic atrial fibrillation.", + "The patient had amiodarone-induced thyrotoxicosis.", + "The thyrotoxicosis resulted in recurrent hemodynamic instability.", + "The indication for total thyroidectomy was established.", + "Total thyroidectomy was performed.", + "The thyroidectomy was performed using local anesthesia combined with a hypnosis-analgesia technique.", + "The intervention was uneventful.", + "The post-operative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_1529_en.txt", + "fulltext": "We present the case of a 28-year-old Hispanic female born with severe Ebstein anomaly of the tricuspid valve. She was initially palliated with right ventricular plication, tricuspid valve repair, and atrial septal defect closure at 5 years of age. She subsequently underwent placement of a 25 mm Hancock™ valve in the tricuspid position and creation of a superior cavopulmonary anastomosis. She developed a high-grade heart block for which an epicardial dual-chamber pacemaker was placed, also at 5 years of age. There was no history of atrial arrhythmia. Her surgical intervention culminated in tricuspid valve removal with patch occlusion of the right ventricle and a fenestrated extracardiac Fontan at 12 years of age. Due to hypoxia, her fenestration was occluded at 25 years of age with a 6 mm Amplatzer™ Septal Occluder via cardiac catheterization, with resulting improvement in oxygen saturations by ∼15% .\nThe patient presented to an outside emergency department with 5 days of chest pain, progressive dyspnoea, and fatigue. On the day of presentation, she had become short of breath with minimal exertion. She denied recent illnesses or travel. The patient was hypoxic on arrival at the outside facility with an oxygen saturation of 78%, which improved to 88% on 4 L of oxygen by nasal cannulation. On physical exam, she was tachypnoeic but comfortable appearing without accessory muscle use. She had a well-healed median sternotomy scar. Pulmonary auscultation demonstrates clear lung fields with good airflow. Her cardiac exam was notable for a single S1 and S2, and non-pulsatile jugular venous distension consistent with her known Fontan physiology. The remainder of her exam was benign. An electrocardiogram (ECG) demonstrated sinus tachycardia at a rate of 117 b.p.m. and a right bundle branch block that was pre-existing . Her laboratory evaluation demonstrated a haemoglobin of 14.8 g/dL (normal range, 11.5–16.0), haematocrit of 45.3% (37–47), and platelets of 203 K/μL (130–400). There was no evidence of infectious processes. Her international normalized ratio (INR) was 1.15 (≤1). Brain natriuretic peptide and troponin were not elevated. A helical chest computed tomographic angiography (CTA) was obtained and interpreted as showing a submassive pulmonary embolism (PE) with no contrast filling the proximal branch pulmonary arteries.\nHer non-cardiac history included hypothyroidism and polycystic ovarian syndrome, for which she took levothyroxine and metformin, respectively. She also had a history of COVID-19 infection, 11 months prior to her presentation, which did not require treatment. The patient had a history of miscarriages with unknown aetiology. She was on rivaroxaban, a direct oral anticoagulant (DOAC) for chronic thromboprophylaxis in the setting of her Fontan physiology. She had recently become pregnant but unfortunately experienced another miscarriage; in this setting, she had discontinued and not reinitiated her anticoagulation.\nThe differential diagnosis for hypoxia in a patient with a Fontan includes the presence of a Fontan fenestration, venovenous collateral vessels, pulmonary arteriovenous malformations, PE, acute pulmonary processes such as infection, and anaemia.\nThe patient was haemodynamically stable and was started on an infusion of unfractionated heparin and transferred to our facility for further management. On exam, she was well-appearing and remained short of breath with hypoxia, though she was able to speak in full sentences. Her lungs were clear bilaterally. Her cardiac examination demonstrated a regular rate and rhythm, a single S1 and single S2, and no murmurs or gallop. Her capillary refill was <3 s, and she had no oedema. A D-dimer was obtained and was elevated at 8.48 μg/mL fibrinogen equvalent units (FEU). We reviewed the CTA . She underwent cardiac catheterization to better elucidate the cause of her shortness of breath and desaturation. Her Fontan pressure was noted to be elevated at 21 mmHg (previously 14 mmHg 2 years prior). Angiography demonstrated a large thrombus in the right lower pulmonary artery branch, with additional thrombi in the subsegmental branches ( and ). The proximal right pulmonary artery and the entire left pulmonary artery were free of thrombi.\nFollowing confirmation of the right lower pulmonary artery emboli in the setting of elevated Fontan pressures and significant symptomatic hypoxia, it was decided that the patient would benefit from embolectomy. Using the transcatheter Penumbra Indigo™ Aspiration System, the larger right lower pulmonary artery branch segment and three additional subsegmental branches were addressed. A significant clot was removed , and post-aspiration angiography demonstrated resolution of the filling defect ( and ).\nThe patient tolerated the procedure well. Following the procedure, she was restarted on rivaroxaban and her heparin drip was discontinued. She was weaned off supplemental oxygen and discharged home 2 days post-procedure with an oxygen saturation of 92% on room air.\nThe patient remains well in follow-up. An outpatient thrombophilia workup was obtained and was negative for antiphospholipid syndrome, factor V Leiden, rheumatologic pathology, or other known causes. Given her Fontan physiology and PE, she was instructed to continue life-long anticoagulation and has remained free of further thrombo-embolic events since admission. She continues to be followed by adult congenital cardiology. In follow-up, at 1 year after the event, she has remained well. She remained on full-dose anticoagulation, which has been well tolerated without bleeding complications or recurrent thrombo-embolic events.", + "fulltext_subclaims": [ + "The patient is a 28-year-old Hispanic female.", + "She was born with severe Ebstein anomaly of the tricuspid valve.", + "She was initially palliated with right ventricular plication, tricuspid valve repair, and atrial septal defect closure at 5 years of age.", + "She subsequently underwent placement of a 25 mm Hancock™ valve in the tricuspid position.", + "She had a superior cavopulmonary anastomosis.", + "She developed a high-grade heart block.", + "An epicardial dual-chamber pacemaker was placed at 5 years of age.", + "There was no history of atrial arrhythmia.", + "She had tricuspid valve removal with patch occlusion of the right ventricle and a fenestrated extracardiac Fontan at 12 years of age.", + "Her fenestration was occluded at 25 years of age with a 6 mm Amplatzer™ Septal Occluder via cardiac catheterization.", + "Her oxygen saturations improved by ∼15% after fenestration occlusion.", + "She presented with 5 days of chest pain, progressive dyspnoea, and fatigue.", + "On the day of presentation, she had shortness of breath with minimal exertion.", + "She denied recent illnesses or travel.", + "She was hypoxic on arrival with an oxygen saturation of 78%.", + "Her oxygen saturation improved to 88% on 4 L of oxygen by nasal cannulation.", + "She had a well-healed median sternotomy scar.", + "Pulmonary auscultation demonstrated clear lung fields with good airflow.", + "Her cardiac exam was notable for a single S1 and S2, and non-pulsatile jugular venous distension.", + "An electrocardiogram demonstrated sinus tachycardia at a rate of 117 b.p.m.", + "The ECG showed a right bundle branch block that was pre-existing.", + "Her haemoglobin was 14.8 g/dL.", + "Her INR was 1.15.", + "A helical chest CTA showed a submassive pulmonary embolism.", + "The CTA showed no contrast filling the proximal branch pulmonary arteries.", + "She had a history of hypothyroidism.", + "She took levothyroxine.", + "She had a history of polycystic ovarian syndrome.", + "She took metformin.", + "She had a history of a prior COVID-19 infection.", + "The prior infection did not require treatment.", + "She had a history of miscarriages with unknown aetiology.", + "She was on rivaroxaban for chronic thromboprophylaxis.", + "She had recently become pregnant but experienced another miscarriage.", + "She discontinued and did not reinitiate anticoagulation after the miscarriage.", + "The differential diagnosis for hypoxia in a patient with a Fontan includes the presence of a Fontan fenestration.", + "The differential diagnosis includes venovenous collateral vessels.", + "The differential diagnosis includes pulmonary arteriovenous malformations.", + "The differential diagnosis includes pulmonary embolism.", + "The differential diagnosis includes acute pulmonary processes such as infection.", + "The differential diagnosis includes anaemia.", + "The patient was started on an infusion of unfractionated heparin.", + "She was transferred to the facility for further management.", + "A D-dimer was elevated at 8.48 μg/mL fibrinogen equivalent units.", + "She underwent cardiac catheterization.", + "Her Fontan pressure was elevated at 21 mmHg.", + "Angiography demonstrated a large thrombus in the right lower pulmonary artery branch.", + "Angiography showed additional thrombi in subsegmental branches.", + "The proximal right pulmonary artery and the entire left pulmonary artery were free of thrombi.", + "It was decided that the patient would benefit from embolectomy.", + "The transcatheter Penumbra Indigo™ Aspiration System was used.", + "The larger right lower pulmonary artery branch segment was addressed.", + "Three additional subsegmental branches were addressed.", + "A significant clot was removed.", + "Post-aspiration angiography demonstrated resolution of the filling defect.", + "The patient was restarted on rivaroxaban.", + "The heparin drip was discontinued.", + "She was weaned off supplemental oxygen.", + "She was discharged home 2 days post-procedure.", + "Her oxygen saturation was 92% on room air at discharge.", + "An outpatient thrombophilia workup was negative for antiphospholipid syndrome.", + "The thrombophilia workup was negative for factor V Leiden.", + "The workup was negative for rheumatologic pathology.", + "The workup was negative for other known causes.", + "She was instructed to continue life-long anticoagulation.", + "She has remained free of further thrombo-embolic events since admission.", + "She continues to be followed by adult congenital cardiology.", + "At 1 year after the event, she has remained well.", + "She remained on full-dose anticoagulation.", + "The anticoagulation has been well tolerated.", + "There have been no bleeding complications.", + "There have been no recurrent thrombo-embolic events." + ], + "summary": "A 28-year-old female with a history of Ebstein anomaly of the tricuspid valve status post-Fontan presented with chest pain and acute hypoxia. Computed tomographic angiography (CTA) reported a submassive pulmonary embolism (PE). She was initiated on a heparin drip. Catheterization demonstrated elevated Fontan pressures and a large thrombus in the right lower pulmonary artery that was removed with an aspiration device. The patient was transitioned to a direct oral anticoagulant (DOAC) following the procedure.", + "summary_subclaims": [ + "The patient is a 28-year-old female.", + "The patient has a history of Ebstein anomaly of the tricuspid valve.", + "The patient had a Fontan procedure.", + "The patient presented with chest pain.", + "The patient presented with acute hypoxia.", + "Computed tomographic angiography reported a submassive pulmonary embolism.", + "She was initiated on a heparin drip.", + "Catheterization demonstrated elevated Fontan pressures.", + "Catheterization showed a large thrombus in the right lower pulmonary artery.", + "The thrombus was removed with an aspiration device.", + "The patient was transitioned to a direct oral anticoagulant following the procedure." + ] + }, + { + "id": "multiclinsum_test_3339_en.txt", + "fulltext": "The case we present begins at 5 years of age in a boy who 'eats and sleeps a lot', initially attributed to a sedentary lifestyle. However, at 7 years of age he suffers two episodes of generalized tonic-clonic seizures with altered natremia, which raise the alarm. His first admission concludes a hypothalamic-pituitary axis dysfunction, with no significant findings in the complementary tests. In addition, his behavior, defiant and aggressive for his age, draws attention. After a polysomnography with multiple latency tests at the discharge of his first admission, he is diagnosed with narcolepsy type 1 (without cataplexy, but with low levels of hypocretin-1: 58.2 pg/mL). Thus, the hypersomnolence they attributed to being a 'sleepy boy' is now justified, although the rest of the symptoms of narcolepsy (cataplexy, sleep paralysis and hallucinations) were never present. During the following four years, symptoms and signs of a significant hypothalamic dysfunction are added, including altered thermoregulation (cold skin), hyperprolactinemia, hypothyroidism, stagnation of height and weight gain of 18 kilos in one year, which guide the definitive diagnosis of ROHHAD. The imaging studies with magnetic resonance ruled out structural lesions, as well as neural tumors, with the performance of a 123I-MIBG scintigraphy. Successive polysomnographies showed a deterioration of his quality of sleep, at the expense of hypoventilation during sleep, which could be documented by transcutaneous capnography, which showed a partial pressure of carbon dioxide (pCO2) > 50 mmHg during 72% of sleep and a mean pCO2 of 52.1 mmHg, with significant O2 desaturation in the absence of data of sleep apnoea. For all this, the patient received a multitude of treatments (topiramate, risperidone, levotiroxina, bi-level positive airway pressure at night and strict control of caloric and hydric intake). In addition, immunoglobulins, corticosteroids, rituximab, cyclophosphamide and etanercept were used. Nothing was effective to reverse, or at least stop, the progress of the disease, which in the last admissions associated significant malnutrition (obesity), dehydration, episodes of uncontrollable agitation with self and hetero aggressiveness, which required the use of parenteral nutrition and sedation. Finally, he died at 11 years of age, after six years from the onset of symptoms and four from the diagnosis of ROHHAD.\n", + "fulltext_subclaims": [ + "The case begins at 5 years of age in a boy who 'eats and sleeps a lot', initially attributed to a sedentary lifestyle.", + "At 7 years of age, he suffers two episodes of generalized tonic-clonic seizures with altered natremia.", + "The first admission concludes a hypothalamic-pituitary axis dysfunction.", + "Complementary tests show no significant findings.", + "He is diagnosed with narcolepsy type 1 without cataplexy.", + "Hypocretin-1 levels are 58.2 pg/mL.", + "The hypersomnolence is now justified as narcolepsy.", + "The rest of the symptoms of narcolepsy (cataplexy, sleep paralysis, and hallucinations) were never present.", + "Over the following four years, symptoms of significant hypothalamic dysfunction are added.", + "Imaging studies with magnetic resonance rule out structural lesions.", + "A 123I-MIBG scintigraphy is performed.", + "Successive polysomnographies show deterioration of sleep quality.", + "Transcutaneous capnography shows a partial pressure of carbon dioxide (pCO2) > 50 mmHg during 72% of sleep.", + "The mean pCO2 is 52.1 mmHg.", + "There is significant O2 desaturation in the absence of data of sleep apnoea.", + "The patient receives multiple treatments including topiramate, risperidone, levotiroxina, bi-level positive airway pressure at night, and strict control of caloric and hydric intake.", + "Immunoglobulins, corticosteroids, rituximab, cyclophosphamide, and etanercept are used.", + "Nothing is effective to reverse or stop the progress of the disease.", + "The patient dies at 11 years of age.", + "The patient dies six years from the onset of symptoms.", + "The patient dies four years from the diagnosis of ROHHAD." + ], + "summary": "Child, 5 years old, with signs of obesity and somnolence. At 7 years old, he had two tonic-clonic seizures and over the next four years, he showed symptoms and signs of a significant hypothalamic dysfunction. After multiple tests, he was diagnosed with ROHHAD. Despite multiple treatments, the patient died at 11 years old.\n", + "summary_subclaims": [ + "The child is 5 years old.", + "The child has signs of obesity.", + "The child has somnolence.", + "At 7 years old, the child had two tonic-clonic seizures.", + "Over the next four years, the child showed symptoms and signs of a significant hypothalamic dysfunction.", + "The patient was diagnosed with ROHHAD.", + "Despite multiple treatments, the patient died at 11 years old." + ] + }, + { + "id": "multiclinsum_test_2277_en.txt", + "fulltext": "Here, we report on a 53-year old man with stage IV adenocarcinoma of the lung with no predictive genetic abnormalities (no EGFR mutation, no ALK or ROS1 translocation). On his initial computed tomography (CT) scan, he presented with multiple bilateral pulmonary nodules, masses in mediastinal lymph nodes, liver, and ribs. The patient had no history of auto-immune disorders. MRI of the skull revealed 2 cerebral lesions, which were treated by irradiation with one fraction of 20 Gray and showed consecutive regression. A subsequent palliative chemotherapy with cisplatin and pemetrexed led to disease stabilization after four cycles. Pemetrexed was continued as maintenance therapy. Two months later, progression of several lesions prompted a second line therapy with the PD-1 inhibitor nivolumab. Serological testing for human immunodeficiency, hepatitis B and C virus infections were negative. Under PD-1 blockade peripheral lesions regressed and quality of life improved. Soon thereafter, however, walking ability deteriorated, and cranial MRI showed a new parieto-temporal lesion in proximity of the formerly irradiated masses . Suggestive of further metastatic spread, this new lesion was irradiated with 24 Gray over 7 days , and nivolumab continued. A few days later, the patient was admitted to the emergency department with progressive gait disturbance and speech difficulties. He had no clincial symptoms for auto-immune disorders such as a systemic lupus erythematodes or generalized vasculitis. Corticosteroid treatment was initiated and provided partial relief only. MRI demonstrated progression of the newly irradiated lesion , whereas extracerebral masses remained stable. The progressive brain lesion was surgically removed and subjected to neuropathological examination.\nHistopathological analysis revealed necrotizing encephalitis with no evidence of metastatic lung cancer . The dimensions correlated with the radiographic size of the lesion (diameter approximately 3.3 cm). Staining for cytokeratins (CK22), performed on all paraffin embedded specimens was negative . A high perivascular density of CD45 positive cells was found with predominance of PD-1 positive T cells over B cells (CD20, PD-1, CD4 and CD8 staining, Fig.). Staining of CD68 demonstrated accompanying resorptive changes of the brain tissue . We also found a predominance of CD8 positive T cells over CD4 positive T cells . PD-L1 expressing cells were sparse . Further analysis of infectious diseases including Toxoplasma were negative (not shown). Parallel panel sequencing (Oncomine™ Comprehensive Cancer Panel, Thermo Fisher) was performed on the initial lung biopsy as well as on DNA extracted from the necrotizing encephalitis. Most prevalent mutations identified in the primary tumor and present in ATM, TP53, and NOTCH1 could not be detected in the brain lesion. This result confirms our histological findings, making it unlikely that tumor cells had been present in the biopsied brain region. We hypothesized that the brain lesion was the consequences of an autoimmune phenomenon during PD-1 blockade.\nTo evaluate for a potential autoimmune syndrome, we screened for anti-neuronal autoantibodies, as well as antinuclear antibodies (ANA). No antibodies against neuronal antigens (i.e., Hu, Yo, Ri, CV2, Ma1, Ma2/Ta, and amphiphysin, NMDA, GAD65) could be detected, but high titers of antinuclear anti-SSA/Ro and anti-SSB/La antibodies were found (>240 U/mL, reference <10 U/mL). High antibody titers against SSA/Ro (Ro52, Ro60) were already found in serum samples that were taken before the initiation of anti-PD-1 treatment. Inflammatory chemokines and cytokines in serum were measured by a flow cytometry bead assay that allows measurement of 13 inflammatory chemokines or cytokines simultaneously (both from Biolegend). Binding of chemokines/cytokines to the beads were measured by a Fortessa analyzer (BD Biosciences). Multiplex analysis of serum samples showed a measurable level of TNFα at the time point when the encephalitis was diagnosed (25.4 pg/mL). At other time points, the TNFα level was below the detection limit. Measurement of inflammatory chemokines showed an increase of blood levels upon treatment initiation with anti-PD-1 antibody including CCL11, IP-10, and MIP-3α . Only MIP-1β and IL-8 were increased at the time point of resection of the encephalitic lesion . The increase in inflammatory chemokines and also TNFα in our patient supported the presence of an inflammatory process. Moreover, when histological cerebellum sections from an unrelated healthy control individual were incubated with patient’s serum taken at the time point when the vasculitis was diagnosed, a strong staining of the endothelial layers of cerebellar vessels was found . Testing of control cerebellar sections with control serum or patient’s serum before nivolumab treatment showed no staining . However, increasing concentrations with pre-PD-1 serum from the patient led to some but overall weaker endothelial staining (not shown) indicating that the anti-vascular antibodies were present before PD-1 blockade, but the titer was lower.\nThe patient’s neurological symptoms rapidly improved after excision of the lesion. Nivolumab treatment was stopped and corticosteroids were tapered over the course of two months. Follow-up imaging of head and chest showed slowly progressive pulmonary lesions and a new neocortical contrast agent-enhancing lesion, which was asymptomatic at the time of imaging. This new lesion was interpreted as encephalitis, and corticosteroids were administered again. In parallel, a second line chemotherapy with docetaxel was initiated. After three cycles of chemotherapy, restaging showed a partial response of the lung lesions and a regression of the cerebral lesion.", + "fulltext_subclaims": [ + "The patient is a 53-year-old man with stage IV adenocarcinoma of the lung.", + "The patient had no predictive genetic abnormalities.", + "The patient had no EGFR mutation.", + "The patient had no ALK or ROS1 translocation.", + "On the initial CT scan, the patient had multiple bilateral pulmonary nodules.", + "On the initial CT scan, the patient had masses in mediastinal lymph nodes.", + "On the initial CT scan, the patient had liver lesions.", + "On the initial CT scan, the patient had rib lesions.", + "The patient had no history of auto-immune disorders.", + "MRI of the skull revealed 2 cerebral lesions.", + "The cerebral lesions were treated by irradiation with one fraction of 20 Gray.", + "The cerebral lesions showed consecutive regression.", + "A subsequent palliative chemotherapy with cisplatin and pemetrexed led to disease stabilization after four cycles.", + "Pemetrexed was continued as maintenance therapy.", + "Two months later, progression of several lesions prompted second line therapy with the PD-1 inhibitor nivolumab.", + "Serological testing for human immunodeficiency, hepatitis B and C virus infections were negative.", + "Under PD-1 blockade, peripheral lesions regressed.", + "Quality of life improved under PD-1 blockade.", + "Walking ability deteriorated soon after PD-1 blockade.", + "Cranial MRI showed a new parieto-temporal lesion in proximity of the formerly irradiated masses.", + "The new parieto-temporal lesion was irradiated with 24 Gray over 7 days.", + "Nivolumab was continued after irradiation of the new parieto-temporal lesion.", + "The patient was admitted to the emergency department with progressive gait disturbance and speech difficulties.", + "The patient had no clinical symptoms for auto-immune disorders such as systemic lupus erythematodes or generalized vasculitis.", + "Corticosteroid treatment was initiated and provided partial relief only.", + "MRI demonstrated progression of the newly irradiated lesion.", + "Extracerebral masses remained stable.", + "The progressive brain lesion was surgically removed.", + "The brain lesion was subjected to neuropathological examination.", + "Histopathological analysis revealed necrotizing encephalitis.", + "There was no evidence of metastatic lung cancer in the brain lesion.", + "The dimensions of the brain lesion correlated with the radiographic size of the lesion.", + "Staining for cytokeratins (CK22) was negative on all paraffin embedded specimens.", + "A high perivascular density of CD45 positive cells was found.", + "There was a predominance of PD-1 positive T cells over B cells.", + "Staining of CD68 demonstrated accompanying resorptive changes of the brain tissue.", + "There was a predominance of CD8 positive T cells over CD4 positive T cells.", + "PD-L1 expressing cells were sparse.", + "Further analysis of infectious diseases including Toxoplasma were negative.", + "Parallel panel sequencing was performed on the initial lung biopsy.", + "Parallel panel sequencing was performed on DNA extracted from the necrotizing encephalitis.", + "Most prevalent mutations identified in the primary tumor and present in ATM, TP53, and NOTCH1 could not be detected in the brain lesion.", + "This result confirms our histological findings.", + "It is unlikely that tumor cells had been present in the biopsied brain region.", + "We hypothesized that the brain lesion was the consequence of an autoimmune phenomenon during PD-1 blockade.", + "We screened for anti-neuronal autoantibodies.", + "We screened for antinuclear antibodies (ANA).", + "No antibodies against neuronal antigens could be detected.", + "High titers of antinuclear anti-SSA/Ro and anti-SSB/La antibodies were found.", + "High antibody titers against SSA/Ro were already found in serum samples taken before the initiation of anti-PD-1 treatment.", + "Multiplex analysis of serum samples showed a measurable level of TNFα at the time point when the encephalitis was diagnosed.", + "At other time points, the TNFα level was below the detection limit.", + "Measurement of inflammatory chemokines showed an increase of blood levels upon treatment initiation with anti-PD-1 antibody including CCL11, IP-10, and MIP-3α.", + "Only MIP-1β and IL-8 were increased at the time point of resection of the encephalitic lesion.", + "The increase in inflammatory chemokines and also TNFα supported the presence of an inflammatory process.", + "When histological cerebellum sections from an unrelated healthy control individual were incubated with patient’s serum taken at the time point when the vasculitis was diagnosed, a strong staining of the endothelial layers of cerebellar vessels was found.", + "Testing of control cerebellar sections with control serum or patient’s serum before nivolumab treatment showed no staining.", + "Increasing concentrations with pre-PD-1 serum from the patient led to some but overall weaker endothelial staining.", + "The patient’s neurological symptoms rapidly improved after excision of the lesion.", + "Nivolumab treatment was stopped.", + "Corticosteroids were tapered over the course of two months.", + "Follow-up imaging of head and chest showed slowly progressive pulmonary lesions.", + "Follow-up imaging showed a new neocortical contrast agent-enhancing lesion.", + "The new neocortical contrast agent-enhancing lesion was asymptomatic at the time of imaging.", + "The new neocortical contrast agent-enhancing lesion was interpreted as encephalitis.", + "Corticosteroids were administered again.", + "A second line chemotherapy with docetaxel was initiated.", + "After three cycles of chemotherapy, restaging showed a partial response of the lung lesions.", + "After three cycles of chemotherapy, restaging showed a regression of the cerebral lesion." + ], + "summary": "Here, we describe a case of autoimmune cerebral vasculitis/encephalitis after PD-1 inhibitor treatment for metastatic adenocarcinoma of the lung. Upon PD-1 blockade, the patient developed cerebral lesions, while having disease stabilization of extracranial metastases. Imaging suggested that the patient had new progressing brain metastases. Despite stereotactic irradiation the lesions progressed further. The largest lesion became symptomatic and had to be surgically resected. On examination, cerebral vasculitis was detected but not evidence of metastatic lung cancer. Analysis of the patient's serum revealed the presence of antinuclear antibodies that were already present before starting PD-1 blockade. In addition, we also found anti-vascular endothelial antibodies in the serum.", + "summary_subclaims": [ + "The patient had metastatic adenocarcinoma of the lung.", + "The patient received PD-1 inhibitor treatment.", + "The patient developed cerebral lesions after PD-1 blockade.", + "The patient had disease stabilization of extracranial metastases.", + "Imaging suggested new progressing brain metastases.", + "The lesions progressed further despite stereotactic irradiation.", + "The largest lesion became symptomatic and had to be surgically resected.", + "Cerebral vasculitis was detected.", + "There was no evidence of metastatic lung cancer.", + "The patient's serum had antinuclear antibodies.", + "The antinuclear antibodies were already present before starting PD-1 blockade.", + "The patient's serum had anti-vascular endothelial antibodies." + ] + }, + { + "id": "multiclinsum_test_2518_en.txt", + "fulltext": "A 38-year-old Caucasian man presented with worsening central vision OS of 1-week duration. His medical history was significant for recurrent tonsillitis but otherwise negative. He had been diagnosed as having “strep throat” twice in the last 3 months and prescribed amoxicillin 500 mg twice per day for 10 days both times without formal rapid strep testing. He recovered from each instance of tonsillitis within 5–7 days. He had no history of ophthalmic conditions or prior surgery. He denied taking any daily medications or using eye drops. He grew up in Kansas City, Missouri, United States of America, and owned a dog but denied recent travel or exposure to ticks. He and his wife have lived in Austin, Texas, USA, for several years. He works as an information technology specialist. He is a former cigarette smoker who quit 8 years ago, he drinks alcohol socially, and he denied any history of illicit drug use. His family history is significant for maternal diabetes and paternal hypertension.\nHis uncorrected visual acuity was 20/20 in his right eye (OD) and 20/50 OS. His pupils were equally round and reactive, and intraocular pressures were normal. The ocular adnexa were normal on external examination. The anterior chamber and vitreous were quiet bilaterally. A dilated fundus examination OD was unremarkable. A dilated fundus examination OS showed a normal optic nerve, scant hyperpigmentation at the inferotemporal border of the disc, and a whitish sub-retinal lesion temporal to the fovea with a small associated hemorrhage. Ultra-widefield fundus photography is shown in Fig. . A general medical examination was unremarkable. He was afebrile with a temperature of 36.7 °C (98.0 °F), heart rate of 73 beats per minute, right arm cuff blood pressure of 113/70 mmHg, respiratory rate of 16 breaths per minute, and 98% oxygen saturation on room air. His oropharynx was clear without exudates, his lungs were clear to auscultation, his heart was without murmur or arrhythmia, he had no rashes, and all cranial nerves II–XII were intact with no gross motor or sensory deficits, and he had normal gait.\nOptical coherence tomography (OCT) showed a hyperreflective sub-retinal elevation with an associated small pocket of fluid. Fluorescein angiography showed a focal area of hyperfluorescence temporal to the fovea in late phase. Indocyanine green (ICG) angiography showed early blockage with mild late leakage and isolated focal hypocyanescent areas. OCT angiography showed a coralliform vascular complex in the outer retina that originated from within the choroid and traversed the RPE and Bruch’s membrane into the sub-retinal space. His examination and ocular imaging were consistent with inflammatory CNVM OS with associated fluid collection, so he was initially treated with an intravitreal bevacizumab 1.25 mg/0.05 mL injection OS. Regarding his laboratory findings, his white blood cell count was 8.4 × 103 per mm3, hemoglobin 12.5 g/dL, platelets 222 × 103 per mm3, prothrombin time 14.5 seconds, international normalized ratio 1.26, blood urea nitrogen 9 mg/dL, creatinine 0.8 mg/dL, aspartate aminotransferase 22 u/L, alanine aminotransferase 27 u/L, and total bilirubin 0.5 mg/dL. Rapid plasma reagin, QuantiFERON-TB Gold, antinuclear antibody profile, and toxoplasmosis titers were non-reactive or unremarkable. His chest X-ray showed a calcified nodule in the upper lung field of his right lung, later confirmed with chest computed tomography.\nOne week after initial presentation and treatment with bevacizumab, his visual acuity improved to 20/25 OS, and OCT showed improvement of the sub-retinal fluid . A 2-week taper of orally administered prednisone starting at 60 mg per day and ending at 5 mg per day was prescribed to treat the inflammatory component of the CNVM. He was referred to pulmonology, and an additional workup revealed elevated serum IgG4 levels at 248 mg/dL (reference 4–86). He was also referred to otolaryngology for his history of recurrent tonsillitis, for which he underwent bilateral tonsillectomy. The specimen showed significant staining for IgG4 on histopathology. After completion of the first orally administered prednisone course, he developed left upper eyelid blepharitis, which did not resolve after initial treatment with antibiotic ointment and warm compresses. During the next 4 months, he received two more intravitreal bevacizumab 1.25 mg/0.05 mL injections for recurrence of sub-retinal fluid associated with inflammatory CNVM in the setting of biopsy-proven IgG4-RD, as well as a 1-month taper of orally administered prednisone starting at 60 mg per day and ending at 5 mg per day, after which the blepharitis resolved. He experienced improvement in his visual acuity with each injection. Six months after initial presentation, he was started on rituximab infusions 1000 mg every 2 weeks in order to decrease circulating IgG4 levels. The CNVM had decreased in size by this point . He is seen by his retina subspecialist (CJ) every 2 months for examination and anti-VEGF therapy as needed.", + "fulltext_subclaims": [ + "A 38-year-old Caucasian man presented with worsening central vision OS of 1-week duration.", + "He had been diagnosed as having 'strep throat' twice in the last 3 months.", + "He was prescribed amoxicillin 500 mg twice per day for 10 days both times.", + "He recovered from each instance of tonsillitis within 5–7 days.", + "He had no history of ophthalmic conditions or prior surgery.", + "He denied taking any daily medications or using eye drops.", + "He grew up in Kansas City, Missouri, United States of America.", + "He owns a dog.", + "He and his wife have lived in Austin, Texas, USA, for several years.", + "He works as an information technology specialist.", + "He is a former cigarette smoker who quit 8 years ago.", + "He drinks alcohol socially.", + "He denied any history of illicit drug use.", + "His family history is significant for maternal diabetes and paternal hypertension.", + "His uncorrected visual acuity was 20/20 in his right eye (OD) and 20/50 OS.", + "A dilated fundus examination OS showed a whitish sub-retinal lesion temporal to the fovea with a small associated hemorrhage.", + "Optical coherence tomography showed a hyperreflective sub-retinal elevation with an associated small pocket of fluid.", + "Fluorescein angiography showed a focal area of hyperfluorescence temporal to the fovea in late phase.", + "OCT angiography showed a coralliform vascular complex in the outer retina that originated from within the choroid and traversed the RPE and Bruch’s membrane into the sub-retinal space.", + "His examination and ocular imaging were consistent with inflammatory CNVM OS with associated fluid collection.", + "He was initially treated with an intravitreal bevacizumab 1.25 mg/0.05 mL injection OS.", + "His white blood cell count was 8.4 × 103 per mm3.", + "His hemoglobin was 12.5 g/dL.", + "His platelets were 222 × 103 per mm3.", + "His prothrombin time was 14.5 seconds.", + "His international normalized ratio was 1.26.", + "His blood urea nitrogen was 9 mg/dL.", + "His creatinine was 0.8 mg/dL.", + "His aspartate aminotransferase was 22 u/L.", + "His alanine aminotransferase was 27 u/L.", + "His total bilirubin was 0.5 mg/dL.", + "Rapid plasma reagin, QuantiFERON-TB Gold, antinuclear antibody profile, and toxoplasmosis titers were non-reactive or unremarkable.", + "His chest X-ray showed a calcified nodule in the upper lung field of his right lung.", + "One week after initial presentation and treatment with bevacizumab, his visual acuity improved to 20/25 OS.", + "A 2-week taper of orally administered prednisone starting at 60 mg per day and ending at 5 mg per day was prescribed.", + "He was referred to pulmonology.", + "An additional workup revealed elevated serum IgG4 levels at 248 mg/dL.", + "He was referred to otolaryngology for his history of recurrent tonsillitis.", + "He underwent bilateral tonsillectomy.", + "The specimen showed significant staining for IgG4 on histopathology.", + "After completion of the first orally administered prednisone course, he developed left upper eyelid blepharitis.", + "He received two more intravitreal bevacizumab 1.25 mg/0.05 mL injections for recurrence of sub-retinal fluid.", + "He received a 1-month taper of orally administered prednisone starting at 60 mg per day and ending at 5 mg per day.", + "He experienced improvement in his visual acuity with each injection.", + "Six months after initial presentation, he was started on rituximab infusions 1000 mg every 2 weeks.", + "The CNVM had decreased in size by this point.", + "He is seen by his retina subspecialist every 2 months for examination and anti-VEGF therapy as needed." + ], + "summary": "A 38-year-old Caucasian man with a history of recurrent tonsillitis presented with blurry vision in his left eye of 1-week duration and was diagnosed as having inflammatory choroidal neovascular membrane. An infectious workup was negative, but his serum immunoglobulin G4 level was elevated at 248 mg/dL (reference 4-86), and a subsequent tonsillectomy for a repeat episode of tonsillitis revealed increased immunoglobulin G4 staining on histopathology, thus confirming the diagnosis of immunoglobulin G4-related disease. The inflammatory choroidal neovascular membrane was treated with intravitreal bevacizumab injections and orally administered prednisone resulting in improved visual acuity and choroidal neovascular membrane regression. He later received rituximab infusions for immunoglobulin G4-related disease.", + "summary_subclaims": [ + "The patient is a 38-year-old Caucasian man.", + "The patient has a history of recurrent tonsillitis.", + "The patient had blurry vision in his left eye for 1 week.", + "The patient was diagnosed as having inflammatory choroidal neovascular membrane.", + "An infectious workup was negative.", + "The patient's serum immunoglobulin G4 level was elevated at 248 mg/dL.", + "The reference range for serum immunoglobulin G4 is 4-86 mg/dL.", + "A tonsillectomy was performed for a repeat episode of tonsillitis.", + "The tonsillectomy specimen showed increased immunoglobulin G4 staining on histopathology.", + "The diagnosis of immunoglobulin G4-related disease was confirmed.", + "The inflammatory choroidal neovascular membrane was treated with intravitreal bevacizumab injections.", + "The inflammatory choroidal neovascular membrane was treated with orally administered prednisone.", + "The treatment resulted in improved visual acuity.", + "The treatment resulted in choroidal neovascular membrane regression.", + "The patient later received rituximab infusions for immunoglobulin G4-related disease." + ] + }, + { + "id": "multiclinsum_test_2392_en.txt", + "fulltext": "A 13-year-old female patient presented to the Department of Endodontics with complaint of mild pain in the maxillary right anterior tooth that had persisted for 10 d.\nThe pain in the upper right anterior tooth started 10 d before presentation. During that time, the patient had taken anti-inflammatory drugs whenever she felt the pain. Since the drugs had only provided temporary pain relief, she wanted to get it checked.\nThe patient’s history of past illness was irrelevant.\nThe patient’s personal and family histories were unremarkable.\nOn physical examination, the maxillary right lateral incisor (tooth #7 by the universal numbering system) was found to be slightly rotated, without caries, restorations or fractures; it appeared identical to the maxillary left lateral incisor, without any coronal morphological variation. The tooth was slightly tender on percussion and had grade I mobility, but no pockets were detected. The tooth was considered non-vital as it did not respond to electric and thermal pulp vitality tests.\nRadiographic examination revealed an unusual configuration of root canals in tooth #7, with an invagination extending to the apex, suggesting the possibility of DI Oehler’s type IIIB and a periapical radiolucency. A panoramic radiography was undertaken to ascertain the root canal anatomy of the maxillary lateral incisor on the other side of the arch, which was found to be normal.", + "fulltext_subclaims": [ + "A 13-year-old female patient presented to the Department of Endodontics with complaint of mild pain in the maxillary right anterior tooth that had persisted for 10 d.", + "The pain in the upper right anterior tooth started 10 d before presentation.", + "The patient had taken anti-inflammatory drugs whenever she felt the pain.", + "The drugs had only provided temporary pain relief.", + "The patient’s history of past illness was irrelevant.", + "The patient’s personal and family histories were unremarkable.", + "On physical examination, the maxillary right lateral incisor (tooth #7 by the universal numbering system) was found to be slightly rotated.", + "The tooth was without caries, restorations or fractures.", + "The tooth appeared identical to the maxillary left lateral incisor, without any coronal morphological variation.", + "The tooth was slightly tender on percussion.", + "The tooth had grade I mobility.", + "No pockets were detected.", + "The tooth was considered non-vital as it did not respond to electric and thermal pulp vitality tests.", + "Radiographic examination revealed an unusual configuration of root canals in tooth #7.", + "Radiographic examination revealed an invagination extending to the apex.", + "Radiographic examination suggested the possibility of DI Oehler’s type IIIB.", + "Radiographic examination revealed a periapical radiolucency.", + "A panoramic radiography was undertaken to ascertain the root canal anatomy of the maxillary lateral incisor on the other side of the arch.", + "The root canal anatomy of the maxillary lateral incisor on the other side of the arch was found to be normal." + ], + "summary": "A 13-year-old female patient presented with mild pain in the maxillary right lateral incisor (#7) for 10-15 d. On examination, the tooth was slightly rotated, with slight tenderness on percussion and grade I mobility but with no caries, pockets or restorations and non-vital pulp (via vitality tests). Radiographic examination revealed unusual configuration of the tooth's root canals, with an enamel-lined invagination extending to the apex, suggesting the possibility of DI Oehler's type IIIB and a periapical radiolucency. Widening the access cavity lingually revealed one distinct buccal orifice and two distinct palatal orifices; under higher magnification of a dental operating microscope (DOM), the mesio-palatal and disto-palatal orifices were observed as connected by a C-shaped groove. The root canals were prepared with hand K-files following a step-back technique, and obturated using a combination technique of lateral condensation and vertical compaction. At the 6-year follow-up, the patient was asymptomatic, and the periapical radiography displayed significant healing around the apical end of the root.", + "summary_subclaims": [ + "The patient is a 13-year-old female.", + "The patient had mild pain in the maxillary right lateral incisor (#7) for 10-15 d.", + "On examination, the tooth was slightly rotated.", + "There was slight tenderness on percussion.", + "There was grade I mobility.", + "There were no caries.", + "There were no pockets.", + "There were no restorations.", + "The pulp was non-vital via vitality tests.", + "Radiographic examination revealed an unusual configuration of the tooth's root canals.", + "An enamel-lined invagination extending to the apex was observed.", + "The possibility of DI Oehler's type IIIB was suggested.", + "A periapical radiolucency was noted.", + "Widening the access cavity lingually revealed one distinct buccal orifice.", + "Widening the access cavity lingually revealed two distinct palatal orifices.", + "Under higher magnification of a dental operating microscope, the mesio-palatal and disto-palatal orifices were observed as connected by a C-shaped groove.", + "The root canals were prepared with hand K-files following a step-back technique.", + "The root canals were obturated using a combination technique of lateral condensation and vertical compaction.", + "At the 6-year follow-up, the patient was asymptomatic.", + "The 6-year follow-up periapical radiography displayed significant healing around the apical end of the root." + ] + }, + { + "id": "multiclinsum_test_2297_en.txt", + "fulltext": "A 27-year-old male patient underwent annual health checkup, and a hyperechoic lesion was incidentally discovered in the tail of the pancreas via abdominal ultrasound. He was referred to our hospital for possible surgery with an inconclusive diagnosis of pNEN. He has no family history of diseases including pancreatic disorders. The blood cell count, biochemistry, and coagulation tests showed absence of abnormal findings. The carcinoembryonic antigen (CEA) level was 4.4 ng/ml, while the carcinoembryonic antigen (CA) 19-9 level was 23.1 U/ml, both of which were within normal range.\nAbdominal computed tomography (CT) examination revealed a well-defined mass measuring 13 mm in the tail of the pancreas. The tumor showed slightly low density compared with the pancreatic parenchyma on plain CT , and enhancement in the arterial phase and equal density with the pancreatic parenchyma in the portal phase and equilibrium phase on dynamic enhanced CT . Tumor abutment to the splenic artery and vein without encasement was observed. The regional lymph nodes were not significantly enlarged, and distant metastases were not noted. Abdominal magnetic resonance imaging (MRI) examination revealed a homogeneous mass with low intensity on T1-weighted image (T1WI) and high intensity on T2-weighted image (T2WI) and diffusion-weighted image (DWI), and a slightly high intensity on the apparent diffusion coefficient-map (ADC-map) in the pancreatic tail . Magnetic resonance cholangiopancreatography (MRCP) showed a high-intensity irregular lesion with slightly indistinct margins without stenosis and dilatation of the main pancreatic duct in the tail of the pancreas . Endoscopic ultrasound (EUS) revealed a slightly hyperechoic mass with distinct borders and homogeneous interior in the tail of the pancreas . Color flow Doppler imaging showed abundant internal blood flow inside the tumor . The tumor had no visible internal septum and cystic components. The cytopathologic findings by EUS-fine needle aspiration (EUS-FNA) revealed epithelial cells with poor atypia showing a glandular duct structure.\nAlthough a definitive pathological diagnosis could not be obtained, the tumor was preoperatively diagnosed as non-functioning pNEN larger than 10 mm based on the findings of enhanced CT and MRI and EUS-FNA cytology; thus, minimally invasive surgical resection was indicated. Solid-type SCA was one of the possible preoperative differential diagnoses, since the EUS showed a slightly hyperechoic lesion that was a distinctive ultrasonographic feature of a microcystic SCA. As tumor abutment to the splenic artery and vein was observed and spleen preservation was desirable, laparoscopic spleen-preserving distal pancreatectomy was performed following the Warshaw method. The operation was carried out using the 5-port approach. No extrapancreatic invasion of the tumor was observed. In order to preserve the splenic inflow, the distal part of the splenic artery was divided at the proximal site of the root of the left gastroepiploic artery. The operation was considered complete after confirming the absence of changes in the color tone of the spleen. The operation time was 300 min, and the estimated blood loss was 5 ml. The postoperative course was uneventful, and the patient was discharged from our hospital on postoperative day 18.\nMacroscopically, the tumor was a well-defined, round, and solid mass without cystic components measuring 15 mm . Microscopically, it appeared as a well-defined lesion with thick fibrous interstitium , covered by a membrane , and composed of epithelial cells with clear vesicles forming microcysts . The epithelial cells were positive for periodic acid Schiff (PAS) staining before the diastase treatment and negative for PAS staining after the treatment ; the tumor was pathologically diagnosed as microcystic SCA based on the World Health Organization (WHO) classification.", + "fulltext_subclaims": [ + "A 27-year-old male patient underwent annual health checkup.", + "A hyperechoic lesion was incidentally discovered in the tail of the pancreas via abdominal ultrasound.", + "He was referred to our hospital for possible surgery with an inconclusive diagnosis of pNEN.", + "He has no family history of diseases including pancreatic disorders.", + "The blood cell count, biochemistry, and coagulation tests showed absence of abnormal findings.", + "The carcinoembryonic antigen (CEA) level was 4.4 ng/ml.", + "The carcinoembryonic antigen (CA) 19-9 level was 23.1 U/ml.", + "Both the CEA and CA 19-9 levels were within normal range.", + "Abdominal computed tomography (CT) examination revealed a well-defined mass measuring 13 mm in the tail of the pancreas.", + "The tumor showed slightly low density compared with the pancreatic parenchyma on plain CT.", + "The tumor showed enhancement in the arterial phase on dynamic enhanced CT.", + "The tumor showed equal density with the pancreatic parenchyma in the portal phase and equilibrium phase on dynamic enhanced CT.", + "Tumor abutment to the splenic artery and vein without encasement was observed.", + "The regional lymph nodes were not significantly enlarged.", + "Distant metastases were not noted.", + "Abdominal magnetic resonance imaging (MRI) examination revealed a homogeneous mass with low intensity on T1-weighted image (T1WI).", + "The mass showed high intensity on T2-weighted image (T2WI) and diffusion-weighted image (DWI).", + "The mass showed a slightly high intensity on the apparent diffusion coefficient-map (ADC-map) in the pancreatic tail.", + "Magnetic resonance cholangiopancreatography (MRCP) showed a high-intensity irregular lesion with slightly indistinct margins.", + "MRCP showed no stenosis and dilatation of the main pancreatic duct in the tail of the pancreas.", + "Endoscopic ultrasound (EUS) revealed a slightly hyperechoic mass with distinct borders and homogeneous interior in the tail of the pancreas.", + "Color flow Doppler imaging showed abundant internal blood flow inside the tumor.", + "The tumor had no visible internal septum and cystic components.", + "The cytopathologic findings by EUS-fine needle aspiration (EUS-FNA) revealed epithelial cells with poor atypia showing a glandular duct structure.", + "A definitive pathological diagnosis could not be obtained.", + "The tumor was preoperatively diagnosed as non-functioning pNEN larger than 10 mm based on the findings of enhanced CT and MRI and EUS-FNA cytology.", + "Minimally invasive surgical resection was indicated.", + "Solid-type SCA was one of the possible preoperative differential diagnoses.", + "The EUS showed a slightly hyperechoic lesion that was a distinctive ultrasonographic feature of a microcystic SCA.", + "Laparoscopic spleen-preserving distal pancreatectomy was performed following the Warshaw method.", + "The operation was carried out using the 5-port approach.", + "No extrapancreatic invasion of the tumor was observed.", + "The distal part of the splenic artery was divided at the proximal site of the root of the left gastroepiploic artery.", + "The operation time was 300 min.", + "The estimated blood loss was 5 ml.", + "The postoperative course was uneventful.", + "The patient was discharged from our hospital on postoperative day 18.", + "Macroscopically, the tumor was a well-defined, round, and solid mass without cystic components measuring 15 mm.", + "Microscopically, it appeared as a well-defined lesion with thick fibrous interstitium, covered by a membrane, and composed of epithelial cells with clear vesicles forming microcysts.", + "The epithelial cells were positive for periodic acid Schiff (PAS) staining before the diastase treatment.", + "The epithelial cells were negative for PAS staining after the treatment.", + "The tumor was pathologically diagnosed as microcystic SCA based on the World Health Organization (WHO) classification." + ], + "summary": "This was a case of a 27-year-old male patient with microcystic SCA causing difficulty in the differential diagnosis from pancreatic neuroendocrine neoplasm (pNEN). A pancreatic tail mass was incidentally discovered on abdominal ultrasound (US). A contrast-enhanced computed tomography (CT) scan revealed a solid tumor measuring 13 mm with early enhancement in the arterial phase at the pancreatic tail. The tumor showed low intensity on T1-weighted magnetic resonance image, high intensity on T2-weighted image, and a slightly hyperechoic mass on endoscopic US (EUS). EUS-fine needle aspiration (EUS-FNA) did not lead to a definitive diagnosis. The tumor was clinically diagnosed as a pNEN, and a laparoscopic spleen-preserving distal pancreatectomy using the Warshaw technique was performed. The final histopathological diagnosis was microcystic SCA.", + "summary_subclaims": [ + "This was a case of a 27-year-old male patient with microcystic SCA.", + "The patient had difficulty in the differential diagnosis from pancreatic neuroendocrine neoplasm.", + "A pancreatic tail mass was incidentally discovered on abdominal ultrasound.", + "A contrast-enhanced computed tomography scan revealed a solid tumor measuring 13 mm with early enhancement in the arterial phase at the pancreatic tail.", + "The tumor showed low intensity on T1-weighted magnetic resonance image.", + "The tumor showed high intensity on T2-weighted image.", + "The tumor showed a slightly hyperechoic mass on endoscopic ultrasound.", + "EUS-fine needle aspiration did not lead to a definitive diagnosis.", + "The tumor was clinically diagnosed as a pancreatic neuroendocrine neoplasm.", + "A laparoscopic spleen-preserving distal pancreatectomy using the Warshaw technique was performed.", + "The final histopathological diagnosis was microcystic SCA." + ] + }, + { + "id": "multiclinsum_test_1981_en.txt", + "fulltext": "A 51-year-old Chinese female presented with the incidental finding of a large heterogeneously enhancing mass in the frontal lobes after a computer tomography (CT) scan for minor head injury following a fall . Her past medical history included only adenomyosis and endometrial polyps. No neurological abnormalities were observed.\nMagnetic resonance imaging (MRI) revealed a 76 × 70 × 54 mm mass in both frontal lobes with extension across the midline that was hypointense on T1-weighted, hyperintense on T2-weighted images, and demonstrated avid postgadolinium contrast enhancement . The lesion showed foci of calcification and peripheral cystic components, with mild perilesional edema and significant mass effect. The corpus callosum was displaced posteriorly. Inferiorly, the lesion extended up to the olfactory bulb.\nThe patient underwent gross total resection (GTR) of the tumor. Intraoperatively the tumor was not found to breach ventricles and the tumor was deemed to be entirely extraventricular. Intraoperative frozen section suggested the diagnosis of a high grade glioma. Histology showed a well demarcated cellulartumor with prominent perivascular pseudo-rosettes and very occasional true (ependymal) rosettes. The tumor cells showed enlarged, hyperchromatic, pleomorphic nuclei, a granular ‘salt and pepper’ chromatin pattern, and fibrillary cytoplasm. Mitotic figures, including atypical forms were readily identified. There were areas of palisading necrosis and microvascular proliferation. The Ki-67 proliferative index was about 20%. These features were diagnostic of an anaplastic ependymoma (WHO grade III).\nMRI taken on postoperative day 1 showed no evidence of residual tumor. The patient's postoperative recovery was uneventful. Cerebrospinal fluid (CSF) studies were negative for malignant cells and no drop metastases were detected on neuroaxis MRI. The patient underwent adjuvant intensity- modulated radiation therapy of 60 Grays in 30 fractions to a region encompassing the tumor bed and a 2 cm margin around it over a period of 2 months. At follow up, the patient developed local recurrence in the frontal lobes within 2 months of completing radiotherapy. At 8 months postsurgery, progression of disease locally had caused her to become increasingly drowsy and by then she was wheelchair bound.", + "fulltext_subclaims": [ + "The patient is a 51-year-old Chinese female.", + "The mass was found incidentally after a CT scan for minor head injury following a fall.", + "The mass was located in the frontal lobes.", + "The mass was large and heterogeneously enhancing.", + "The patient's past medical history included adenomyosis and endometrial polyps.", + "No neurological abnormalities were observed.", + "MRI revealed a 76 × 70 × 54 mm mass in both frontal lobes.", + "The mass extended across the midline.", + "The lesion was hypointense on T1-weighted images.", + "The lesion was hyperintense on T2-weighted images.", + "The lesion demonstrated avid postgadolinium contrast enhancement.", + "The lesion showed foci of calcification.", + "The lesion had peripheral cystic components.", + "There was mild perilesional edema.", + "There was significant mass effect.", + "The corpus callosum was displaced posteriorly.", + "The inferior extent of the lesion reached the olfactory bulb.", + "The patient underwent gross total resection of the tumor.", + "Intraoperatively, the tumor was not found to breach ventricles.", + "The tumor was deemed to be entirely extraventricular.", + "Intraoperative frozen section suggested the diagnosis of a high grade glioma.", + "Histology showed a well demarcated cellular tumor.", + "The tumor cells showed enlarged, hyperchromatic, pleomorphic nuclei.", + "The tumor cells had a granular 'salt and pepper' chromatin pattern.", + "Mitotic figures, including atypical forms, were readily identified.", + "There were areas of palisading necrosis.", + "There was microvascular proliferation.", + "The Ki-67 proliferative index was about 20%.", + "The diagnosis was anaplastic ependymoma (WHO grade III).", + "MRI on postoperative day 1 showed no evidence of residual tumor.", + "The patient's postoperative recovery was uneventful.", + "CSF studies were negative for malignant cells.", + "No drop metastases were detected on neuroaxis MRI.", + "The patient underwent adjuvant intensity-modulated radiation therapy.", + "The radiation therapy was 60 Grays in 30 fractions.", + "The radiation therapy was delivered to a region encompassing the tumor bed and a 2 cm margin.", + "The radiation therapy was delivered over a period of 2 months.", + "The patient developed local recurrence in the frontal lobes within 2 months of completing radiotherapy.", + "At 8 months postsurgery, the patient became increasingly drowsy.", + "At 8 months postsurgery, the patient was wheelchair bound." + ], + "summary": "We present a unique case of an anaplastic cortical ependymoma in a 51-year-old female presenting as a butterfly lesion with involvement of both frontal lobes. The patient underwent gross total resection of her tumor with further adjuvant treatment. We present the findings in our case and review the literature surrounding supratentorial ependymomas and their treatment outcomes.", + "summary_subclaims": [ + "The patient is a 51-year-old female.", + "The patient had an anaplastic cortical ependymoma.", + "The tumor presented as a butterfly lesion.", + "The tumor involved both frontal lobes.", + "The patient underwent gross total resection of her tumor.", + "The patient received further adjuvant treatment.", + "The authors present the findings in their case.", + "The authors review the literature surrounding supratentorial ependymomas.", + "The authors review the literature surrounding treatment outcomes." + ] + }, + { + "id": "multiclinsum_test_188_en.txt", + "fulltext": "A 62-year-old Caucasian woman presented with a two-month history of intermittent fever. Her past medical history included hypertension, dyslipidema, coronary artery disease and mild chronic kidney disease. She was found to have Enterococcus faecalis endocarditis of her native, bicuspid, aortic valve. She was treated with vancomycin, gentamicin and penicillin and subsequently underwent aortic valve replacement (AVR) with a Saint Jude valve in October of 2004. Her postoperative course was complicated by evacuation of a mediastinal hematoma, splenectomy and a partial colectomy with diverting colostomy for hemorrhagic colitis. The patient had been discharged and re-admitted multiple times and was ultimately transferred to the Oklahoma University Medical Center in May 2005.\nUpon transfer, the patient complained of dyspnea, orthopnea and lower-extremity swelling. She was afebrile and hemodynamically stable. Her physical examination revealed jugular venous distention, a III/VI systolic murmur in the right second intercostal space, and bilateral lower-extremity edema to the knees. No peripheral stigmata of endocarditis were identified.\nNine blood cultures obtained over a five-day period were positive for Candida lusitaniae. Susceptibility testing was performed on the initial isolate only and revealed sensitivity to amphotericin B, caspofungin and fluconazole . Transesophageal echocardiography revealed multiple vegetations on a partially dehiscent mechanical aortic valve with severe aortic valvular regurgitation and a left ventricular ejection fraction of 50% . Therapy with caspofungin was initiated prior to obtaining results of susceptibility testing on the initial isolate and was continued based on the minimal inhibitory concentration (MIC). The patient eventually underwent repeat AVR with coronary artery bypass grafting. Vegetations were noted on her removed prosthetic valve . Her post-operative course was complicated by a chest hematoma which was evacuated. Despite eventual clearance of her fungemia, the patient died from multi-organ failure in June 2005.", + "fulltext_subclaims": [ + "The patient was a 62-year-old Caucasian woman.", + "She had a two-month history of intermittent fever.", + "Her past medical history included hypertension.", + "Her past medical history included dyslipidemia.", + "Her past medical history included coronary artery disease.", + "She had mild chronic kidney disease.", + "She was found to have Enterococcus faecalis endocarditis of her native, bicuspid, aortic valve.", + "She was treated with vancomycin, gentamicin and penicillin.", + "She underwent aortic valve replacement (AVR) with a Saint Jude valve in October of 2004.", + "Her postoperative course was complicated by evacuation of a mediastinal hematoma.", + "Her postoperative course was complicated by splenectomy.", + "Her postoperative course was complicated by a partial colectomy with diverting colostomy for hemorrhagic colitis.", + "The patient had been discharged and re-admitted multiple times.", + "She was transferred to the Oklahoma University Medical Center in May 2005.", + "Upon transfer, the patient complained of dyspnea.", + "Upon transfer, the patient complained of orthopnea.", + "Upon transfer, the patient complained of lower-extremity swelling.", + "She was afebrile.", + "She was hemodynamically stable.", + "Her physical examination revealed jugular venous distention.", + "Her physical examination revealed a III/VI systolic murmur in the right second intercostal space.", + "Her physical examination revealed bilateral lower-extremity edema to the knees.", + "No peripheral stigmata of endocarditis were identified.", + "Nine blood cultures obtained over a five-day period were positive for Candida lusitaniae.", + "Susceptibility testing was performed on the initial isolate only.", + "The initial isolate was sensitive to amphotericin B.", + "The initial isolate was sensitive to caspofungin.", + "The initial isolate was sensitive to fluconazole.", + "Transesophageal echocardiography revealed multiple vegetations on a partially dehiscent mechanical aortic valve.", + "Transesophageal echocardiography revealed severe aortic valvular regurgitation.", + "Transesophageal echocardiography revealed a left ventricular ejection fraction of 50%.", + "Therapy with caspofungin was initiated prior to obtaining results of susceptibility testing on the initial isolate.", + "The patient eventually underwent repeat AVR with coronary artery bypass grafting.", + "Vegetations were noted on her removed prosthetic valve.", + "Her post-operative course was complicated by a chest hematoma which was evacuated.", + "The patient died from multi-organ failure in June 2005." + ], + "summary": "We describe a case of prosthetic valve endocarditis with Candida lusitaniae in an immunocompetent 62-year-old woman following aortic valve replacement. In vitro testing demonstrated that our isolate was sensitive to amphotericin B, caspofungin and fluconazole.", + "summary_subclaims": [ + "The patient was a 62-year-old woman.", + "The patient was immunocompetent.", + "The patient had a prosthetic valve endocarditis.", + "The causative organism was Candida lusitaniae.", + "The infection occurred following aortic valve replacement.", + "In vitro testing demonstrated that the isolate was sensitive to amphotericin B.", + "In vitro testing demonstrated that the isolate was sensitive to caspofungin.", + "In vitro testing demonstrated that the isolate was sensitive to fluconazole." + ] + }, + { + "id": "multiclinsum_test_1174_en.txt", + "fulltext": "A 70-year-old man (weight 70 kg, body mass index 25.7 kg/m2) with underlying hypertension and dyslipidemia underwent an elective open hernioplasty for right inguinal hernia under ambulatory surgery. He had normal airway features: good mouth opening, Mallampati score of 1, thyromental distance > 6 cm and normal tongue protrusion. General anesthesia was induced with intravenous propofol 200 mg plus fentanyl 100 μg and a size 4 LMA ProtectorTM Airway was placed smoothly in a single attempt by a senior resident. The cuff was inflated with 25 ml of air and the black line indicator on the cuff pilot valve remained within the green zone throughout the surgery. However, we did not check the intra-cuff pressure using manometry. The oropharyngeal leak pressure was 25 cmH2O. The sternal notch test and bubble test were performed after insertion to confirm the placement of the LMA protector . Anesthesia was maintained with a mixture of sevoflurane and oxygen/air. The patient’s breathing was supported with a pressure support of 8 cmH2O, which generated a tidal volume of 400–450 ml and the maximum minute ventilation attained was 12 L/min with peak pressures of 8–10 cmH2O. He was placed in a supine position with standard American Society of Anesthesiologists monitoring for the surgery which lasted for 180 minutes. The surgery was uneventful, and the patient’s vital signs were stable throughout. Postoperatively, the LMA was removed smoothly when he was awake. Moreover, blood stains or minimal secretions were not observed on the device.\nAt the post anesthesia care unit, the patient complained of difficulty in chewing food and a weird tongue movement. He had no voice changes or altered taste sensation. On examination, the patient’s tongue was seen to be deviated to the left during active protrusion . All sensations of the tongue were intact and there were no tongue fasciculations or wasting. The neurological examination revealed no lateralizing signs or limb weakness. The gag and cough reflexes as well as other cranial nerves were normal. The patient was referred to the ENT surgeon the same day. The nasoendoscopy examination was unremarkable. The working diagnosis was that of an isolated left hypoglossal nerve palsy or neuropraxia. He was allowed to go home the same day with reassurance, oral prednisolone for one week, and instructed for follow up at the ENT outpatient clinic. Neuroimaging was not required. He achieved complete recovery 3 months after the injury (, ) and was subsequently discharged from the follow-up clinic.", + "fulltext_subclaims": [ + "The patient was a 70-year-old man with underlying hypertension and dyslipidemia.", + "He underwent an elective open hernioplasty for right inguinal hernia under ambulatory surgery.", + "He had normal airway features, including good mouth opening, Mallampati score of 1, thyromental distance > 6 cm, and normal tongue protrusion.", + "General anesthesia was induced with intravenous propofol 200 mg plus fentanyl 100 μg.", + "A size 4 LMA ProtectorTM Airway was placed smoothly in a single attempt by a senior resident.", + "The cuff was inflated with 25 ml of air.", + "The black line indicator on the cuff pilot valve remained within the green zone throughout the surgery.", + "We did not check the intra-cuff pressure using manometry.", + "The oropharyngeal leak pressure was 25 cmH2O.", + "The sternal notch test and bubble test were performed after insertion to confirm the placement of the LMA protector.", + "Anesthesia was maintained with a mixture of sevoflurane and oxygen/air.", + "The patient’s breathing was supported with a pressure support of 8 cmH2O.", + "The tidal volume generated was 400–450 ml.", + "The maximum minute ventilation attained was 12 L/min.", + "The peak pressures were 8–10 cmH2O.", + "The patient was placed in a supine position.", + "Standard American Society of Anesthesiologists monitoring was used.", + "The surgery lasted for 180 minutes.", + "The surgery was uneventful.", + "The patient’s vital signs were stable throughout.", + "The LMA was removed smoothly when he was awake.", + "Blood stains or minimal secretions were not observed on the device.", + "The patient complained of difficulty in chewing food and a weird tongue movement.", + "The patient’s tongue was seen to be deviated to the left during active protrusion.", + "All sensations of the tongue were intact.", + "There were no tongue fasciculations or wasting.", + "The neurological examination revealed no lateralizing signs or limb weakness.", + "The gag and cough reflexes as well as other cranial nerves were normal.", + "The working diagnosis was that of an isolated left hypoglossal nerve palsy or neuropraxia.", + "The patient was allowed to go home the same day.", + "He was given oral prednisolone for one week.", + "He was instructed for follow up at the ENT outpatient clinic.", + "Neuroimaging was not required.", + "He achieved complete recovery 3 months after the injury." + ], + "summary": "We report a case of postoperative unilateral hypoglossal nerve palsy after uncomplicated use of the LMA Protector. To the best of our knowledge, this could be the second reported case.", + "summary_subclaims": [ + "The case involves postoperative unilateral hypoglossal nerve palsy.", + "The hypoglossal nerve palsy occurred after uncomplicated use of the LMA Protector.", + "To the best of our knowledge, this could be the second reported case." + ] + }, + { + "id": "multiclinsum_test_3246_en.txt", + "fulltext": "A 45-year-old female with a past medical history of rheumatoid arthritis and a remote history of chickenpox was referred for evaluation of an 11-day history of recurrent redness, blurriness, mild pain, pressure, discomfort, and decreased vision in the right eye (OD). Prior to her referral to our facility, she was evaluated at an outside clinic with a one-week history of redness and decreased vision OD. She was started on topical difluprednate and atropine for anterior uveitis which she began 2 days before her presentation to our facility.\n\nOn examination, best-corrected visual acuities (BCVA) were 20/100 OD and 20/25 in the left eye (OS). Pupillary examination showed a 1+ relative afferent pupillary defect OD. Intraocular pressures (IOP) were physiologic at 17 mmHg OD and 16 mmHg OS. Slit-lamp examination revealed 1–2+ granulomatous anterior chamber reaction and 3+ vitreous cells OD, and OS was unremarkable. Fundus examination showed optic disc edema and hemorrhages, diffuse retinal whitening, and necrosis with hemorrhagic vasculitis OD, and OS appeared unaffected. A diagnostic anterior chamber paracentesis was performed, and the ocular fluid was positive for VZV by PCR testing. Given the examination findings, she was diagnosed with acute retinal necrosis prompting an in-office intravitreal injection of foscarnet (2.4 mg/0.1 mL) and ganciclovir (2 mg/0.05 mL) along with initiation of oral valacyclovir 2 grams TID. On a 2-week follow-up after the initial presentation, the patient reported improvement in central vision, and BCVAs improved to 20/50 OD and 20/20 OS. Examination revealed persistent vitreous opacity, but the retinitis has improved with consolidation and well-demarcated borders of the retinitis involving the temporal retina.\n\nOn the 6-week follow-up, the patient complained of a sudden loss of vision in the right eye. BCVAs were counting fingers OD and 20/20 OS, and examination revealed retinal detachment OD. The patient underwent surgery for complex rhegmatogenous retinal detachment (RRD) repair and continued to be monitored closely. Postoperatively, the vision gradually improved until two weeks post-surgery when the patient was noted to develop a low-lying inferior retinal detachment with surface proliferative vitreoretinopathy (PVR), prompting a pars plana vitrectomy for retinal detachment repair. This surgery was performed seven weeks after the PVR diagnosis was made, and six months after the patient’s initial presentation at our facility.\n\nAn aqueous humor (AqH) sample of the right eye was obtained during surgery for a chemokine/cytokine profile analysis. The levels of a panel of 22 cytokines and chemokines (ie, IFN-γ, IL-10, IL-12p70, IL-17A, IL-1β, IL-2, IL-5, IL-6, IL-8, TNF-α, IL-18, IL-1RA, IL-1a, IL-1α, IP-10, MCP-1, MIP-1α, MIP-1β, SDF-1α, IL-21, IL-22, IL-23, and IL-27) were tested in triplicate using a multiplex chemiluminescent immunoassay. The concentration of 7 cytokines/chemokines was detected including IFN-γ, TNF-α, IL-8, IL-18, MIP-1β, IP-10, and MCP-1. MCP-1 was the most abundant cytokine (900 pg/mL), while IP-10 was the second most abundant cytokine (800 pg/mL). IL-8 and IL-18 were the third most abundant cytokines, each with a level of 40 pg/mL, while IFN-γ and TNF-α levels of <10 pg/mL were recorded as the least abundant in this patient’s AqH sample.", + "fulltext_subclaims": [ + "The patient is a 45-year-old female.", + "She has a past medical history of rheumatoid arthritis.", + "She has a remote history of chickenpox.", + "She was referred for evaluation of an 11-day history of recurrent redness, blurriness, mild pain, pressure, discomfort, and decreased vision in the right eye.", + "Prior to her referral to our facility, she was evaluated at an outside clinic with a one-week history of redness and decreased vision in the right eye.", + "She was started on topical difluprednate and atropine for anterior uveitis.", + "She began the topical medications 2 days before her presentation to our facility.", + "On examination, best-corrected visual acuity was 20/100 in the right eye.", + "Pupillary examination showed a 1+ relative afferent pupillary defect in the right eye.", + "Intraocular pressure was 17 mmHg in the right eye.", + "Slit-lamp examination revealed 1–2+ granulomatous anterior chamber reaction in the right eye.", + "Fundus examination showed optic disc edema and hemorrhages in the right eye.", + "The ocular fluid was positive for VZV by PCR testing.", + "She was diagnosed with acute retinal necrosis.", + "She received an intravitreal injection of foscarnet (2.4 mg/0.1 mL) in the right eye.", + "She received an intravitreal injection of ganciclovir (2 mg/0.05 mL) in the right eye.", + "She was started on oral valacyclovir 2 grams TID.", + "On a 2-week follow-up, the patient reported improvement in central vision.", + "On a 2-week follow-up, best-corrected visual acuity improved to 20/50 in the right eye.", + "On a 6-week follow-up, the patient complained of a sudden loss of vision in the right eye.", + "Best-corrected visual acuity was counting fingers in the right eye.", + "Examination revealed retinal detachment in the right eye.", + "The patient underwent surgery for complex rhegmatogenous retinal detachment repair.", + "The patient developed a low-lying inferior retinal detachment with surface proliferative vitreoretinopathy two weeks post-surgery.", + "A pars plana vitrectomy was performed for retinal detachment repair.", + "The surgery was performed seven weeks after the PVR diagnosis was made.", + "The surgery was performed six months after the patient’s initial presentation at our facility.", + "An aqueous humor sample was obtained during surgery for a chemokine/cytokine profile analysis.", + "The levels of 22 cytokines and chemokines were tested in triplicate using a multiplex chemiluminescent immunoassay.", + "The concentration of 7 cytokines/chemokines was detected.", + "MCP-1 was the most abundant cytokine at 900 pg/mL.", + "IP-10 was the second most abundant cytokine at 800 pg/mL.", + "IL-8 and IL-18 were the third most abundant cytokines, each at 40 pg/mL.", + "IFN-γ and TNF-α levels were <10 pg/mL." + ], + "summary": "Case 1 was a 45-year-old female, who was evaluated for an 11-day history of recurrent redness, and decreased vision in the right eye (OD) and was diagnosed with acute retinal necrosis. Ocular fluid from anterior chamber paracentesis was positive for varicella zoster virus (VZV) via PCR testing. Subsequently, the patient developed proliferative vitreoretinopathy requiring a pars plana vitrectomy. Ocular fluid sample cytokine/chemokine analysis detected IFN-γ, TNF-α, IL-8, IL-18, MIP-1β, IP-10, and MCP-1 with MCP-1 being the most abundant cytokine.", + "summary_subclaims": [ + "Case 1 was a 45-year-old female.", + "The patient was evaluated for an 11-day history of recurrent redness.", + "The patient had decreased vision in the right eye (OD).", + "The patient was diagnosed with acute retinal necrosis.", + "Ocular fluid from anterior chamber paracentesis was positive for varicella zoster virus (VZV) via PCR testing.", + "The patient developed proliferative vitreoretinopathy.", + "The patient required a pars plana vitrectomy.", + "Ocular fluid sample cytokine/chemokine analysis detected IFN-γ.", + "Ocular fluid sample cytokine/chemokine analysis detected TNF-α.", + "Ocular fluid sample cytokine/chemokine analysis detected IL-8.", + "Ocular fluid sample cytokine/chemokine analysis detected IL-18.", + "Ocular fluid sample cytokine/chemokine analysis detected MIP-1β.", + "Ocular fluid sample cytokine/chemokine analysis detected IP-10.", + "Ocular fluid sample cytokine/chemokine analysis detected MCP-1.", + "MCP-1 was the most abundant cytokine." + ] + }, + { + "id": "multiclinsum_test_2548_en.txt", + "fulltext": "A 59-year-old female presented to the emergency department (ED) with a chief complaint of right lower extremity pain and swelling. Vital signs at triage were temperature (oral) 98.2° Fahrenheit; heart rate 83 beats per minute; respiratory rate 17 breaths per minute; pulse oximetry 99% on room air; and blood pressure of 135/78 millimeters of mercury (mm Hg). The patient had a hospital admission 40 days prior to presentation for PE and right popliteal DVT with a positive nasopharyngeal COVID-19 test. She denied a familial history of hypercoagulable states or a personal history of thromboembolic disease prior to her COVID-19 infection. In the ED, she underwent an ultrasound of the right lower extremity. The ultrasound showed the previously seen right popliteal DVT , as well as interval development of right mid-femoral DVT .\nRepeat COVID-19 nasopharyngeal swab testing was negative. Per the patient, when she was discharged previously she was unable to follow up with a hematologist/oncologist due to COVID-19-related lockdown restrictions but maintained compliance with her apixaban at five milligrams (mg) twice per day. Her international normalized ratio (INR) on presentation was 1.36 (reference range: 0.83–1.09) and her D-dimer was 2054 nanograms per milliliter (ng/mL) (0–500 ng/mL). She was admitted for anti-coagulation and started on low molecular weight heparin (LMWH) at 1 mg per kilogram. Throughout her hospital course, she was placed on warfarin with INR values ranging from 0.98 to 4.14. An echocardiogram was performed that showed a normal size, thickness, and function of the left ventricle. In addition, the right ventricle was normal in size and function. The patient was discharged with 12 mg of warfarin daily with hematology follow-up.\nThe patient had been admitted approximately 40 days prior for submassive bilateral central PE with a right popliteal DVT . A detailed report of her previous admission is warranted given the patient’s previous DVT and PE findings with a positive COVID-19 nasopharyngeal swab test.\nOn ED arrival during the first admission, vital signs at triage were heart rate 120 beats per minute; blood pressure of 150/109 mm Hg; respiratory rate of 22 breaths per minute; and pulse oximetry of 89% on room air. Laboratory studies revealed a 0.89 ng/mL troponin I (0.00–0.05 ng/mL) with the additional following labs: D-dimer 5397 ng/mL and INR of 1.0. The chest computed tomography angiography showed acute bilateral central PE with probable right heart strain with multiple small bilateral peripheral ground glass infiltrates suggestive of COVID-19 pneumonitis. The patient was given at the time a heparin infusion with a bolus based on actual body weight and protocols.\nShe was admitted to the intensive care unit (ICU) and underwent urgent thrombolysis with thrombectomy. During the procedure, one mg per hour of alteplase was catheter directed while mechanical thrombectomy was performed. The total amount of alteplase received was 24 mg. Repeat angiography approximately 24 hours later showed significant improvement in blood flow to the right and left main as well as segmental and subsegmental pulmonary arteries with significant decrease in central clot burden but with residual central filling defects. An echocardiogram was performed during her admission. However, due to all images being suboptimal in quality, the study was technically limited with “probable normal LV systolic function…right ventricle is not well visualized.” During her hospital course, she was placed on 10 mg of apixaban twice a day for one week and transitioned to 5 mg twice a day with which she was discharged on the same schedule. The patient underwent rehabilitation, which included daily exercising. She stated she was compliant with her apixaban medication at 5 mg twice a day.", + "fulltext_subclaims": [ + "The patient is a 59-year-old female.", + "She presented to the emergency department with a chief complaint of right lower extremity pain and swelling.", + "Vital signs at triage included a temperature of 98.2° Fahrenheit.", + "Vital signs at triage included a heart rate of 83 beats per minute.", + "Vital signs at triage included a respiratory rate of 17 breaths per minute.", + "Vital signs at triage included a pulse oximetry of 99% on room air.", + "Vital signs at triage included a blood pressure of 135/78 mm Hg.", + "The patient had a hospital admission 40 days prior to presentation for PE and right popliteal DVT.", + "The patient had a positive nasopharyngeal COVID-19 test 40 days prior to presentation.", + "She denied a familial history of hypercoagulable states.", + "She denied a personal history of thromboembolic disease prior to her COVID-19 infection.", + "In the ED, she underwent an ultrasound of the right lower extremity.", + "The ultrasound showed the previously seen right popliteal DVT.", + "The ultrasound showed interval development of right mid-femoral DVT.", + "Repeat COVID-19 nasopharyngeal swab testing was negative.", + "She was unable to follow up with a hematologist/oncologist due to COVID-19-related lockdown restrictions.", + "She maintained compliance with her apixaban at five milligrams twice per day.", + "Her international normalized ratio (INR) on presentation was 1.36.", + "Her D-dimer was 2054 ng/mL.", + "She was admitted for anti-coagulation.", + "She was started on low molecular weight heparin at 1 mg per kilogram.", + "Throughout her hospital course, she was placed on warfarin.", + "Her INR values ranged from 0.98 to 4.14.", + "An echocardiogram showed a normal size, thickness, and function of the left ventricle.", + "An echocardiogram showed the right ventricle was normal in size and function.", + "The patient was discharged with 12 mg of warfarin daily.", + "The patient had been admitted approximately 40 days prior for submassive bilateral central PE with a right popliteal DVT.", + "On ED arrival during the first admission, vital signs at triage included a heart rate of 120 beats per minute.", + "On ED arrival during the first admission, vital signs at triage included a blood pressure of 150/109 mm Hg.", + "On ED arrival during the first admission, vital signs at triage included a respiratory rate of 22 breaths per minute.", + "On ED arrival during the first admission, vital signs at triage included a pulse oximetry of 89% on room air.", + "Laboratory studies revealed a 0.89 ng/mL troponin I.", + "The chest computed tomography angiography showed acute bilateral central PE.", + "The chest computed tomography angiography showed probable right heart strain.", + "The chest computed tomography angiography showed multiple small bilateral peripheral ground glass infiltrates suggestive of COVID-19 pneumonitis.", + "The patient was given a heparin infusion with a bolus based on actual body weight.", + "She was admitted to the intensive care unit.", + "She underwent urgent thrombolysis with thrombectomy.", + "During the procedure, one mg per hour of alteplase was catheter directed.", + "The total amount of alteplase received was 24 mg.", + "Repeat angiography approximately 24 hours later showed significant improvement in blood flow to the right and left main pulmonary arteries.", + "Repeat angiography approximately 24 hours later showed significant improvement in blood flow to segmental and subsegmental pulmonary arteries.", + "Repeat angiography approximately 24 hours later showed a significant decrease in central clot burden.", + "Repeat angiography approximately 24 hours later showed residual central filling defects.", + "An echocardiogram was performed during her admission.", + "The echocardiogram was technically limited due to suboptimal image quality.", + "The echocardiogram noted probable normal LV systolic function.", + "The echocardiogram noted the right ventricle was not well visualized.", + "During her hospital course, she was placed on 10 mg of apixaban twice a day for one week.", + "She was transitioned to 5 mg of apixaban twice a day.", + "She was discharged on 5 mg of apixaban twice a day.", + "She underwent rehabilitation, which included daily exercising.", + "She stated she was compliant with her apixaban medication at 5 mg twice a day." + ], + "summary": "WWe present an emergency department case of a COVID-19-provoked deep venous thrombosis and pulmonary embolism without a history of venous thromboembolism (VTE), with extension of the VTE despite adherence to apixaban.", + "summary_subclaims": [ + "The case involves a deep venous thrombosis and pulmonary embolism.", + "The deep venous thrombosis and pulmonary embolism were provoked by COVID-19.", + "The patient had no prior history of venous thromboembolism.", + "The venous thromboembolism extended despite adherence to apixaban." + ] + }, + { + "id": "multiclinsum_test_3252_en.txt", + "fulltext": "A 57-year-old female patient with a diagnosis of autosomal dominant polycystic kidney disease underwent DDLT for polycystic liver disease (PCLD). She did not have any background lung disease or smoking history, as shown in her clear preoperative chest radiograph. Her right diaphragm was severely elevated due to PCLD, which caused persistent atelectasis in the right lower lobe. DDLT was performed uneventfully. A small hole was made on the right diaphragm, which was repaired with a multifilament suture, and a thoracic drain was placed. Although the patient required reoperation on postoperative day 2 (POD 2) due to a persistent bile leakage, she recovered well without further major complications.\n\nA chest radiograph revealed a round hypertranslucency with air–fluid levels on the right side since POD 1, and no further evaluation was made at that time. However, because the hypertranslucency persisted, follow-up computed tomography (CT) was performed on POD 18, and revealed an air–fluid level above the diaphragm in the right thoracic cavity. The patient was initially considered to have an intrathoracic hematoma, and thoracoscopic evacuation of the hematoma was planned.\n\nRegarding the immunosuppressants for liver transplantation, tacrolimus and methylprednisolone were initiated intravenously immediately after the transplantation without any induction therapy. No mycophenolate mofetil was used. Tacrolimus was maintained with a target level of 12–16 ng/mL, and methylprednisolone was tapered according to the institutional protocol. Both tacrolimus and methylprednisolone were switched to oral administration when ready. The liver graft was functioning well with normal transaminases and bilirubin levels, and there were no signs of rejection throughout the course. On the day of the surgery for the pneumatocele (POD 19), the doses of tacrolimus and methylprednisolone were 18 and 16 mg/day, respectively.\n\nContrary to our initial expectation, thoracoscopic investigation revealed no intrathoracic hemorrhage; instead, there was a large cystic change inside the lung parenchyma, which was thought to be a pneumatocele that had formed at the basal area of the right lower lobe. Surgical resection was preferred given the risk of pneumatocele infection due to intra-cystic hematoma and immunosuppression for liver transplantation. Wedge resection was satisfactory to preserve as much remaining lung parenchyma as possible. From a different perspective, wedge resection was a better way to lower the risk of postoperative empyema, which is higher in lobectomy or segmentectomy. However, simple wedge resection was impractical considering the thickness of the lung parenchyma adjacent to the pneumatocele. It was thought that if the intra-cystic hematoma was evacuated, the thickness of the adjacent lung parenchyma would become thinner and would allow wedge resection with a stapling device. Therefore, the pneumatocele was incised, and the intra-cystic clot was removed to reduce its size. Wedge resection was subsequently performed using a stapling device. The staple line was reinforced with 4-0 polypropylene sutures, a polyglycolic acid sheet (Gunze, Osaka, Japan), and fibrin glue (KM Biologics, Tokyo, Japan). The postoperative course of the patient was uneventful, and she was discharged 18days after resecting the pneumatocele.\n\nHistopathological examination revealed a cyst-free wall, which consisted of visceral pleura with fibrosis and microvascular proliferation. The parenchymal side of the cyst wall was fibrotic and organized with hemorrhage and bronchiolar dilation.", + "fulltext_subclaims": [ + "The patient is a 57-year-old female.", + "The patient has a diagnosis of autosomal dominant polycystic kidney disease.", + "The patient underwent DDLT for polycystic liver disease.", + "The patient did not have any background lung disease.", + "The patient's preoperative chest radiograph was clear.", + "The patient's right diaphragm was severely elevated due to PCLD.", + "The patient had persistent atelectasis in the right lower lobe.", + "DDLT was performed uneventfully.", + "A small hole was made on the right diaphragm.", + "The hole on the right diaphragm was repaired with a multifilament suture.", + "A thoracic drain was placed.", + "The patient required reoperation on postoperative day 2 due to a persistent bile leakage.", + "A chest radiograph revealed a round hypertranslucency with air–fluid levels on the right side since postoperative day 1.", + "No further evaluation was made at that time.", + "Follow-up computed tomography was performed on postoperative day 18.", + "Computed tomography revealed an air–fluid level above the diaphragm in the right thoracic cavity.", + "The patient was initially considered to have an intrathoracic hematoma.", + "Thoracoscopic evacuation of the hematoma was planned.", + "Tacrolimus and methylprednisolone were initiated intravenously immediately after the transplantation.", + "No mycophenolate mofetil was used.", + "Tacrolimus was maintained with a target level of 12–16 ng/mL.", + "Methylprednisolone was tapered according to the institutional protocol.", + "Both tacrolimus and methylprednisolone were switched to oral administration when ready.", + "The liver graft was functioning well with normal transaminases and bilirubin levels.", + "There were no signs of rejection throughout the course.", + "On the day of the surgery for the pneumatocele, the doses of tacrolimus and methylprednisolone were 18 and 16 mg/day, respectively.", + "Thoracoscopic investigation revealed no intrathoracic hemorrhage.", + "There was a large cystic change inside the lung parenchyma.", + "The cystic change was thought to be a pneumatocele that had formed at the basal area of the right lower lobe.", + "Surgical resection was preferred given the risk of pneumatocele infection due to intra-cystic hematoma and immunosuppression for liver transplantation.", + "Wedge resection was preferred to preserve as much remaining lung parenchyma as possible.", + "Wedge resection was considered a better way to lower the risk of postoperative empyema.", + "Simple wedge resection was impractical considering the thickness of the lung parenchyma adjacent to the pneumatocele.", + "The pneumatocele was incised, and the intra-cystic clot was removed to reduce its size.", + "Wedge resection was subsequently performed using a stapling device.", + "The staple line was reinforced with 4-0 polypropylene sutures.", + "The staple line was reinforced with a polyglycolic acid sheet.", + "The staple line was reinforced with fibrin glue.", + "The postoperative course of the patient was uneventful.", + "The patient was discharged 18 days after resecting the pneumatocele.", + "Histopathological examination revealed a cyst-free wall.", + "The cyst wall consisted of visceral pleura with fibrosis and microvascular proliferation.", + "The parenchymal side of the cyst wall was fibrotic and organized with hemorrhage and bronchiolar dilation." + ], + "summary": "A 57-year-old woman with a diagnosis of autosomal dominant polycystic kidney disease underwent deceased-donor liver transplantation for polycystic liver disease. She did not have any background lung disease, although her right lower lobe was mostly atelectatic due to a remarkably elevated diaphragm. The liver transplant itself was uneventful. A small hole was made in the right diaphragm during the dissection of the liver, but it was successfully repaired without any injury to the lung. On postoperative day 1, the chest radiograph revealed a round hypertranslucency on the right side, which was initially considered subphrenic air retention, and no further evaluation was made at that time. Given that the hypertranslucency persisted, follow-up computed tomography was performed on postoperative day 18, and revealed an air-fluid level above the diaphragm in the right thoracic cavity. Thoracoscopic investigation revealed an intrathoracic hematoma within a pneumatocele in the right lower lobe, which was not detected in the pretransplant computed tomography. The hematoma was removed, and the pneumatocele was resected.", + "summary_subclaims": [ + "The patient is a 57-year-old woman.", + "She has a diagnosis of autosomal dominant polycystic kidney disease.", + "She underwent deceased-donor liver transplantation.", + "The liver transplantation was for polycystic liver disease.", + "She did not have any background lung disease.", + "Her right lower lobe was mostly atelectatic due to a remarkably elevated diaphragm.", + "The liver transplant itself was uneventful.", + "A small hole was made in the right diaphragm during the dissection of the liver.", + "The hole in the right diaphragm was successfully repaired without any injury to the lung.", + "On postoperative day 1, the chest radiograph revealed a round hypertranslucency on the right side.", + "The round hypertranslucency was initially considered subphrenic air retention.", + "No further evaluation was made on postoperative day 1.", + "Follow-up computed tomography was performed on postoperative day 18.", + "Computed tomography revealed an air-fluid level above the diaphragm in the right thoracic cavity.", + "Thoracoscopic investigation revealed an intrathoracic hematoma within a pneumatocele in the right lower lobe.", + "The pneumatocele was not detected in the pretransplant computed tomography.", + "The hematoma was removed.", + "The pneumatocele was resected." + ] + }, + { + "id": "multiclinsum_test_2648_en.txt", + "fulltext": "A 19-year-old male was admitted to the Department of Plastic, hand and reconstructive surgery due to persistant dysaesthesia of the median nerve-supplied area and a soft tissue laceration of the palmar wrist following a wakeboarding accident three days before. As an intermediate wakeboarding athlete starting to wakeboard one year ago, he was wakeboarding on the largest German artificial wakeboarding circled nylon cable system on a lake with a speed of 40 km/h, when the automatic nylon cable system stopped immediately due to an overlapping wire. The male wakeboarder dived in the lake and got struck in the loose nylon cable system with his trunk and the hand. He managed to get off with the trunk still caught with his wrist in the nylon cable, when the nylon cable system was activated by chance and he was pulled 1/4 of the radius of the lake with a speed of 40 km/h, suffering a strangulation of his wrist with immediate numbness of the median-nerve supplied area of the left hand. Furthermore, he had a laceration of the palmar aspect of the wrist covering 0.5 × 5 cm tissue size.\nAt admission in a rural hospital, the two-point discrimination was > 15 mm for the entire interdigital nerves N1–N7 of the left hand as sensory loss in the median-nerve supplied area. The ulnar nerve was found without any pathology. Furthermore, he could not perform a wrist flexion, while wrist extension was possible. The capillary refill was 1s for all five fingertips. No distinct pain in the snuff box area was evident on admission. The left elbow joint had full range of motion, supination and pronation was limited due to persistent pain at the wrist level. Resting on a plaster, he was transferred three days after the initial injury with persistent clinical lesion of the median nerve in our department.\nConventional x-ray of the hand and the wrist found regular articulation without an evident bony lesion. No disruption of the scapular-lunar ligament was noted. Computer tomography of the wrist and the hand proofed regular bony structures . In the operating room dorsal compartment pressure of the forearm was 19 mmHg, at the palmar compartment of the flexor carpi ulnaris muscle 16 mmHg, which were both normal. The median nerve, 72 hours after the initial strangulation injury, appeared with hyperaemia and moderate swelling and limited haematoma in the carpal tunnel more according to a median nerve contusion. The palmar branch of the median nerve was surrounded by a significant haematoma, which was evacuated. The ulnar nerve was inspected and found without any significant signs of injury or haematoma.\nThe laceration area was excised completely and the skin could be closed primarily without compression with one subcutaneous drainage being inserted. On postoperative day 1, the patient regained the sensory function of the hand following 72 hours of acute carpal tunnel syndrome with median nerve contusion with remaining dysaesthesia of the thenar skin supplied by the palmar branch of the median nerve. On postoperative day 5 the patient was discharged home after an uneventful postoperative course. He complained of minor dysaesthesias in the mentioned thenar area with recurrent intensity and was advised to recovery for a total of four weeks before returning to sport.", + "fulltext_subclaims": [ + "A 19-year-old male was admitted to the Department of Plastic, hand and reconstructive surgery.", + "The patient had persistant dysaesthesia of the median nerve-supplied area.", + "The patient had a soft tissue laceration of the palmar wrist.", + "The injury occurred following a wakeboarding accident three days before admission.", + "The patient was wakeboarding on the largest German artificial wakeboarding circled nylon cable system.", + "The automatic nylon cable system stopped immediately due to an overlapping wire.", + "The male wakeboarder dived in the lake and got struck in the loose nylon cable system with his trunk and the hand.", + "The nylon cable system was activated by chance and he was pulled 1/4 of the radius of the lake with a speed of 40 km/h.", + "The patient suffered a strangulation of his wrist with immediate numbness of the median-nerve supplied area of the left hand.", + "The patient had a laceration of the palmar aspect of the wrist covering 0.5 × 5 cm tissue size.", + "At admission in a rural hospital, the two-point discrimination was > 15 mm for the entire interdigital nerves N1–N7 of the left hand.", + "The ulnar nerve was found without any pathology.", + "The patient could not perform a wrist flexion.", + "Wrist extension was possible.", + "The capillary refill was 1s for all five fingertips.", + "No distinct pain in the snuff box area was evident on admission.", + "The left elbow joint had full range of motion.", + "Supination and pronation were limited due to persistent pain at the wrist level.", + "The patient was transferred three days after the initial injury with persistent clinical lesion of the median nerve.", + "Conventional x-ray of the hand and the wrist found regular articulation without an evident bony lesion.", + "No disruption of the scapular-lunar ligament was noted.", + "Computer tomography of the wrist and the hand proved regular bony structures.", + "In the operating room, dorsal compartment pressure of the forearm was 19 mmHg.", + "In the operating room, palmar compartment pressure of the flexor carpi ulnaris muscle was 16 mmHg.", + "The median nerve, 72 hours after the initial strangulation injury, appeared with hyperaemia and moderate swelling.", + "The median nerve had limited haematoma in the carpal tunnel.", + "The palmar branch of the median nerve was surrounded by a significant haematoma.", + "The haematoma surrounding the palmar branch of the median nerve was evacuated.", + "The ulnar nerve was inspected and found without any significant signs of injury or haematoma.", + "The laceration area was excised completely.", + "The skin could be closed primarily without compression.", + "One subcutaneous drainage was inserted.", + "On postoperative day 1, the patient regained the sensory function of the hand following 72 hours of acute carpal tunnel syndrome with median nerve contusion.", + "On postoperative day 1, the patient had remaining dysaesthesia of the thenar skin supplied by the palmar branch of the median nerve.", + "On postoperative day 5, the patient was discharged home after an uneventful postoperative course.", + "The patient complained of minor dysaesthesias in the thenar area.", + "The patient was advised to recover for a total of four weeks before returning to sport." + ], + "summary": "The palmar branch of the median nerve was surrounded by a significant haematoma in addition to the strangulation damage caused by its more superficial location in contrast to the median nerve.", + "summary_subclaims": [ + "The palmar branch of the median nerve was surrounded by a significant haematoma.", + "The palmar branch of the median nerve had strangulation damage.", + "The palmar branch of the median nerve is more superficially located in contrast to the median nerve." + ] + }, + { + "id": "multiclinsum_test_1771_en.txt", + "fulltext": "The case involves Mr. N., a 36-year-old man with no previous medical history, who had returned from a long stay in Ivory Coast for professional activities (about 0–6 months). Since his return to Tunisia, he presented a symptomatology associating fever, headache, asthenia, and diarrhea. A polymerase chain reaction (PCR) test for Covid-19 had previously been performed (before traveling), which was negative. Mr. N. did not seek medical advice and resorted to self-medication including antipyretic and analgesics. On the 5th day, Mr. N.’s condition worsened as he presented a generalized tonic-clonic convulsive seizure, after which he did not regain consciousness. His family members called for medical assistance, but Mr. N. died before the arrival of the emergency units. As a result of an unclear cause of death, a medicolegal autopsy was ordered by the prosecutor, and the body was thus transferred to our department for autopsy. Malaria infection was already suspected at this point upon investigating the death circumstances with his relatives. A postmortem blood sample, on ethylenediamine tetraacetic acid (EDTA) preserved blood sample, was hence referred to the Parasitology Laboratory in order to confirm our assumptions before autopsy. Malaria rapid diagnostic test (RDT) (i.e., rapid diagnostic test for malaria which detects malaria antigens in a person’s blood) was positive. In both thick and thin Giemsa-stained blood smears , numerous Plasmodium falciparum (trophozoites) were found, showing high parasitemia. The percentage of parasitemia was though difficult to assess due to the hemolysis state of the postmortem samples. External examination revealed cyanosis with frank mucocutaneous icterus. Autopsy findings revealed massive congestion and edema of the brain, weighing 1550 g , lungs (weighing 745 g on the right and 640 g on the left), and inner organs. Hepatomegaly was noted (liver weighing 2905 g) with heterogeneous parenchyma on section. The spleen (weighing 385 g) was enlarged with a tense, smooth capsule, and congested parenchyma of brown-black color. Histology showed cerebral gray and white matter with congested capillaries containing numerous parasitized erythrocytes (trophozoites) in each examined brain section. Each cell contained dots of hemozoin pigment (malaria pigment). The same findings were also observed in the histology of the remaining thoracic and abdominal organs . Toxicological analyses did not reveal the presence of any toxic substance that might have been involved in the death.\nBased on histology, autopsy findings, as well as parasitology expertise, the case was considered to have died of fulminant cerebral malaria with multiple organ failure.", + "fulltext_subclaims": [ + "The case involves Mr. N., a 36-year-old man with no previous medical history.", + "Mr. N. had returned from a long stay in Ivory Coast for professional activities.", + "Since his return to Tunisia, he presented a symptomatology associating fever, headache, asthenia, and diarrhea.", + "A polymerase chain reaction (PCR) test for Covid-19 had previously been performed (before traveling), which was negative.", + "Mr. N. did not seek medical advice and resorted to self-medication including antipyretic and analgesics.", + "On the 5th day, Mr. N.’s condition worsened as he presented a generalized tonic-clonic convulsive seizure.", + "After the seizure, Mr. N. did not regain consciousness.", + "Mr. N. died before the arrival of the emergency units.", + "A medicolegal autopsy was ordered by the prosecutor.", + "Malaria infection was already suspected at this point upon investigating the death circumstances with his relatives.", + "A postmortem blood sample, on ethylenediamine tetraacetic acid (EDTA) preserved blood sample, was referred to the Parasitology Laboratory.", + "Malaria rapid diagnostic test (RDT) was positive.", + "In both thick and thin Giemsa-stained blood smears, numerous Plasmodium falciparum (trophozoites) were found, showing high parasitemia.", + "The percentage of parasitemia was difficult to assess due to the hemolysis state of the postmortem samples.", + "External examination revealed cyanosis with frank mucocutaneous icterus.", + "Autopsy findings revealed massive congestion and edema of the brain, weighing 1550 g.", + "The right lung weighed 745 g and the left lung weighed 640 g.", + "Hepatomegaly was noted (liver weighing 2905 g) with heterogeneous parenchyma on section.", + "The spleen (weighing 385 g) was enlarged with a tense, smooth capsule, and congested parenchyma of brown-black color.", + "Histology showed cerebral gray and white matter with congested capillaries containing numerous parasitized erythrocytes (trophozoites) in each examined brain section.", + "Each cell contained dots of hemozoin pigment (malaria pigment).", + "The same findings were also observed in the histology of the remaining thoracic and abdominal organs.", + "Toxicological analyses did not reveal the presence of any toxic substance that might have been involved in the death.", + "Based on histology, autopsy findings, as well as parasitology expertise, the case was considered to have died of fulminant cerebral malaria with multiple organ failure." + ], + "summary": "We present the case of a 36-year-old man who died a few days after returning from a business trip to the Ivory Coast. As a result of an unclear cause of death, a medicolegal autopsy was ordered. Autopsy findings revealed massive congestion and edema of the brain with no other macroscopic abnormalities at organ gross examination. Histology and laboratory tests were conducted revealing a Plasmodium falciparum infection, with numerous parasitized erythrocytes containing dots of hemozoin pigment (malaria pigment) in all examined brain sections and all other organs. Death was attributed to cerebral malaria with multiple organ failure.", + "summary_subclaims": [ + "The patient was a 36-year-old man.", + "The patient died a few days after returning from a business trip to the Ivory Coast.", + "A medicolegal autopsy was ordered due to an unclear cause of death.", + "Autopsy findings revealed massive congestion and edema of the brain.", + "There were no other macroscopic abnormalities at organ gross examination.", + "Histology and laboratory tests were conducted.", + "A Plasmodium falciparum infection was revealed.", + "Numerous parasitized erythrocytes containing dots of hemozoin pigment were found in all examined brain sections.", + "Numerous parasitized erythrocytes containing dots of hemozoin pigment were found in all other organs.", + "Death was attributed to cerebral malaria with multiple organ failure." + ] + }, + { + "id": "multiclinsum_test_801_en.txt", + "fulltext": "The recipient of the blood transfusion was a 16-year-old Sri Lankan boy who has beta thalassaemia major with a co-morbidity of blood transfusion-induced cardiomyopathy. Thalassaemia is the commonest monogenic disease in Sri Lanka . The patient, who is from the Polonnaruwa district in the North Central Province of Sri Lanka gave no history of travel overseas. He had been splenectomized in 2010 and receives monthly blood transfusions. His last transfusion had been on the 21st of April 2021. He developed fever and headache 13 days following the transfusion on 4th May for which he sought treatment from a General Practitioner two days later. He was treated for a viral fever with anti-pyretics and malaria was not suspected nor tested for at this stage of the illness. As the fever did not respond to treatment he was admitted to the General Hospital, Polonnaruwa on the 9th of May 2021 for further investigation and treatment, 18 days after the blood transfusion. As a part of the routine fever surveillance activities carried out in hospitals by the Public Health Field Officer (PHFO) for the AMC, the patient was tested for malaria soon after admission, and was reported positive for P. falciparum by microscopy (parasite density of 51,315/μl with asexual parasites and gametocytes). The diagnosis was also confirmed by polymerase chain reaction testing.\nThe day after admission, when the malaria diagnosis was confirmed the patient was febrile (37.8 °C), had a blood pressure of 90/60 Hgmm and a normal heart rate. Laboratory investigations revealed a haemoglobin (Hb) of 5.4 mg/dl, WBC count of 31,300/μl and a platelet count of 378,000/mm3. The patient was treated with artemisinin-based combination therapy (ACT), artemether-lumefantrine, the first-line treatment for P. falciparum malaria in Sri Lanka, for 3 days at the standard recommended dosage under supervision, based on national malaria treatment guidelines . Routine investigations on liver and other functions were performed.\nThe patient’s clinical condition deteriorated over the first 3 days of treatment. The peripheral blood parasitaemia declined very slowly from a starting density of 51,015 parasites/μl on admission. After 72 h of commencement of anti-malarial treatment the parasitaemia was 7147 parasites/μl, blood pressure remained below normal at 90/50 mmHg, haemoglobin (Hb) level fell to 7.6 mg/dl and the WBC count was 47,430/mm3. He still had irregular spikes of fever. The liver enzymes increased (AST from 86.5 U/L to 250.8 U/L and to 458.9 U/L; and ALT from 62 U/L to 174.3 U/L and 314.9 U/L) over 3 days. Serum C-Reactive Protein was elevated above 100 mg/L. The patient was managed with intravenous inotropes (noradrenalin) because of the poor response of blood pressure to fluid therapy. With parasites persisting in peripheral blood on completion of the ACT course at 72 h, and deterioration of the patient’s clinical condition, further anti-malarial treatment options were considered. The second-line anti-malarial medicine in Sri Lanka, dihydroartemisinin-piperaquine (DHAPPQ) could not be used in this patient because it is contraindicated in cardiomyopathies which the patient suffered from. Treatment with the next option, intravenous artesunate 2.4 mg/kg was, therefore, commenced immediately (i.e. 72 h after starting anti-malarials) and given for a further 3 days while the patient was managed in the Coronary Care Unit of the hospital. Following the last dose of IV artesunate, he was started on a 3-day course of oral artemether-lumefantrine as the recommended practice after parenteral artesunate. By day seven of commencement of treatment, asexual malaria parasites were no longer seen in blood smears, but gametocytes (sexual stages) were present at a density of 270/μl. The patient had improved clinically by then and had a stable blood pressure after withdrawal of inotropes, and liver function test had returned to normal levels (AST- 48.7 U/L and ALT- 25.5 U/L). The gametocyte count decreased gradually to 152 parasites/µl on completion of oral ACT on day 9. A stat dose of primaquine (0.75 mg/ kg−3 tablets) was given on day 10 for its anti-gametocyte activity. The patient was completely cleared of parasites including gametocytes by day 15. Following the transfusion of three units of blood the patient was discharged from hospital on day seventeen (post transfusion Hb was 9.8 mg/dl (27th April 2021). Data on beta thalassaemia patient diagnosed with malaria is provided in Additional file : Table S1.\nUpon diagnosis of malaria in the recipient, information on the blood donor of the last transfusion given to the recipient on the 21st of April 2021 was traced, based on the records maintained by the National Blood Transfusion Service. The donor was a member of the armed forces who had returned to Sri Lanka on the 9th of December 2020 after spending 16 months in South Sudan on a United Nations peacekeeping mission. He was also traced in the AMC database as a person who was being kept under surveillance. While in South Sudan he had taken mefloquine and doxycycline as antimalarial prophylaxis, but reportedly, not on a regular basis. As per guidelines of the AMC, and through the close collaboration that exists with the armed forces, their members arriving from malaria endemic countries are screened for malaria by microscopy and Rapid Diagnostic Tests (RDT) at the airport, or, due to the current COVID-19 pandemic, at COVID quarantine centers where they are kept for 14 days. The first malaria screening of the group of 51 armed forces personnel of whom the blood donor was one, was performed at the airport on the 9th of December 2020 and he and the rest of the group were reported as negative for malaria by microscopy and RDT. He was asymptomatic on arrival and gave no history of malaria while in South Sudan. He had donated blood four months after his return, on the 9th of April 2021 and this blood donation was used on the beta thalassaemia patient. Prior to transfusion the blood product was screened for malaria by microscopy as a routine procedure but was reported as negative. However, when the stored blood smear was examined retrospectively after the incident of transfusion-malaria, it showed P. falciparum parasites (asexual parasites—112 parasites/μl, gametocytes—32 parasites/μl). On testing the asymptomatic donor for malaria on 10th May 2021, soon after the recipient was diagnosed, he was found to be positive for malaria by microscopy at a very low density of 32 parasites/ μl with ring and gametocyte stages of P. falciparum. On admission his Hb was 15.2 g/dl. He was admitted to the same hospital ward as the blood recipient a day later, and was treated with an oral ACT artemether-lumefantrine and a single dose of primaquine . His blood parasitaemia was completely cleared on day 3 of treatment and was discharged from hospital on the 4th day.\nReactive parasitological and entomological surveillance activities commenced the same day as the diagnosis of malaria was made in the blood recipient and donor respectively in accordance with AMC’s prevention of re-establishment strategy. Primary and secondary case surveillance was carried out covering all residents of houses within a radius of 1 km of residencies of both the recipient and the donor . A total of two hundred persons were screened by microscopy and were found negative for malaria. The blood donor had 51 travel contacts in the armed forces group which had returned with him from South Sudan who were screened by microscopy, and they all reported negative for malaria.\nEntomological surveillance was conducted within a radius of 1 km of the residence of the blood recipient. With the reporting of larvae of Anopheles culicifacies, the primary vector of malaria in Sri Lanka, larval source management, space spraying and distribution of long-lasting insecticidal nets (LLINs) were carried out. Entomological surveillance was also carried out around all sites where, the blood donor had stayed night over the past 14 days from blood donation up to diagnosis, and larvae of primary vector was found in two locations. The same vector control methods mentioned above were applied at these sites as well.", + "fulltext_subclaims": [ + "The recipient of the blood transfusion was a 16-year-old Sri Lankan boy.", + "The patient has beta thalassaemia major.", + "The patient has a co-morbidity of blood transfusion-induced cardiomyopathy.", + "Thalassaemia is the commonest monogenic disease in Sri Lanka.", + "The patient is from the Polonnaruwa district in the North Central Province of Sri Lanka.", + "The patient gave no history of travel overseas.", + "The patient had been splenectomized in 2010.", + "The patient receives monthly blood transfusions.", + "The patient's last transfusion had been on the 21st of April 2021.", + "The patient developed fever and headache 13 days following the transfusion on 4th May.", + "The patient sought treatment from a General Practitioner two days after symptoms began.", + "The patient was treated for a viral fever with anti-pyretics.", + "Malaria was not suspected nor tested for at this stage of the illness.", + "The patient was admitted to the General Hospital, Polonnaruwa on the 9th of May 2021.", + "The patient was 18 days after the blood transfusion at the time of admission.", + "The patient was tested for malaria soon after admission.", + "The patient was reported positive for P. falciparum by microscopy.", + "The parasite density was 51,315/μl with asexual parasites and gametocytes.", + "The diagnosis was also confirmed by polymerase chain reaction testing.", + "The patient was febrile (37.8 °C) the day after admission.", + "The patient had a blood pressure of 90/60 mmHg the day after admission.", + "The patient had a normal heart rate the day after admission.", + "Laboratory investigations revealed a haemoglobin (Hb) of 5.4 mg/dl.", + "The patient was treated with artemisinin-based combination therapy (ACT), artemether-lumefantrine.", + "The treatment was given for 3 days at the standard recommended dosage under supervision.", + "The treatment was based on national malaria treatment guidelines.", + "The patient’s clinical condition deteriorated over the first 3 days of treatment.", + "The peripheral blood parasitaemia declined very slowly from 51,015 parasites/μl on admission.", + "After 72 h of anti-malarial treatment, the parasitaemia was 7147 parasites/μl.", + "The patient’s blood pressure remained below normal at 90/50 mmHg.", + "The patient’s haemoglobin (Hb) level fell to 7.6 mg/dl.", + "The patient’s WBC count was 47,430/mm3.", + "The patient still had irregular spikes of fever.", + "The liver enzymes increased over 3 days.", + "The patient was managed with intravenous inotropes (noradrenalin).", + "The patient was managed in the Coronary Care Unit of the hospital.", + "Intravenous artesunate 2.4 mg/kg was commenced immediately.", + "The intravenous artesunate was given for a further 3 days.", + "Following the last dose of IV artesunate, the patient was started on a 3-day course of oral artemether-lumefantrine.", + "By day seven of treatment, asexual malaria parasites were no longer seen in blood smears.", + "Gametocytes were present at a density of 270/μl.", + "The patient had improved clinically by day seven.", + "The patient had a stable blood pressure after withdrawal of inotropes.", + "The patient’s liver function tests had returned to normal levels.", + "The gametocyte count decreased to 152 parasites/µl on completion of oral ACT on day 9.", + "A stat dose of primaquine (0.75 mg/kg) was given on day 10.", + "The patient was completely cleared of parasites including gametocytes by day 15.", + "The patient was discharged from hospital on day seventeen.", + "The post transfusion Hb was 9.8 mg/dl.", + "The blood donor of the last transfusion given to the recipient on the 21st of April 2021 was traced.", + "The donor was a member of the armed forces.", + "The donor had returned to Sri Lanka on the 9th of December 2020.", + "The donor had spent 16 months in South Sudan.", + "The donor had taken mefloquine and doxycycline as antimalarial prophylaxis.", + "The donor reportedly did not take the prophylaxis on a regular basis.", + "The donor was screened for malaria by microscopy and RDT at the airport.", + "The donor was reported as negative for malaria by microscopy and RDT.", + "The donor was asymptomatic on arrival.", + "The donor gave no history of malaria while in South Sudan.", + "The donor donated blood on the 9th of April 2021.", + "The blood donation was used on the beta thalassaemia patient.", + "The blood product was screened for malaria by microscopy as a routine procedure.", + "The blood product was reported as negative.", + "When the stored blood smear was examined retrospectively, it showed P. falciparum parasites.", + "The stored blood smear showed 112 asexual parasites/μl.", + "The stored blood smear showed 32 gametocytes/μl.", + "On testing the asymptomatic donor for malaria on 10th May 2021, he was found to be positive for malaria by microscopy.", + "The donor had a very low density of 32 parasites/μl.", + "The donor had ring and gametocyte stages of P. falciparum.", + "The donor was admitted to the same hospital ward as the blood recipient.", + "The donor was treated with an oral ACT artemether-lumefantrine.", + "The donor was given a single dose of primaquine.", + "The donor’s blood parasitaemia was completely cleared on day 3 of treatment.", + "The donor was discharged from hospital on the 4th day.", + "Reactive parasitological and entomological surveillance activities commenced the same day as the diagnosis.", + "Primary and secondary case surveillance was carried out covering all residents within a 1 km radius.", + "A total of two hundred persons were screened by microscopy.", + "All two hundred persons were found negative for malaria.", + "The blood donor had 51 travel contacts in the armed forces group.", + "The 51 travel contacts were screened by microscopy.", + "All 51 travel contacts reported negative for malaria.", + "Entomological surveillance was conducted within a 1 km radius of the residence of the blood recipient.", + "Larvae of Anopheles culicifacies were reported.", + "Larval source management, space spraying, and distribution of LLINs were carried out.", + "Entomological surveillance was also carried out around all sites where the blood donor had stayed overnight.", + "Larvae of the primary vector were found in two locations.", + "The same vector control methods were applied at these sites." + ], + "summary": "A 17-year-old splenectomized beta thalassaemia patient developed a transfusion-induced Plasmodium falciparum malaria infection following a blood transfusion 18 days earlier. The blood donor was an armed forces personnel who returned from South Sudan following a United Nations peace-keeping mission. The blood recipient's malaria infection took a complicated clinical course with elevated liver enzymes, lowered blood pressure and a prolonged parasite clearance time of 7 days but he recovered fully after two courses of artemether-lumefantrine interrupted by a course of intravenous artesunate. The prolonged parasite clearance is likely due to lack of splenic clearance of dead or damaged intra-erythrocytic parasites (due to a splenectomy) rather than to the parasite strain being resistant to artemisinin or the partner drug. This is corroborated by the fact that the blood donor's infection responded to artemether-lumefantrine with parasites being cleared on day 3. The blood donor who had not displayed signs or symptoms of malaria, had been screened for malaria on arrival in Sri Lanka and was negative on both microscopy and RDT. At the point of blood donation a blood smear examined microscopically was also reported negative for malaria, but retrospectively, the preserved smear of the donor's blood was found to contain P. falciparum parasites at a very low density. The donor when tested after the transfusion-induced case was diagnosed, also tested positive for malaria and was treated.", + "summary_subclaims": [ + "The patient is a 17-year-old splenectomized beta thalassaemia patient.", + "The patient developed a transfusion-induced Plasmodium falciparum malaria infection.", + "The blood transfusion occurred 18 days before the infection was diagnosed.", + "The blood donor was an armed forces personnel who returned from South Sudan.", + "The blood donor had participated in a United Nations peace-keeping mission.", + "The blood recipient's malaria infection had a prolonged parasite clearance time of 7 days.", + "The patient recovered fully after two courses of artemether-lumefantrine.", + "The patient's treatment was interrupted by a course of intravenous artesunate.", + "The prolonged parasite clearance is likely due to lack of splenic clearance of dead or damaged intra-erythrocytic parasites.", + "The blood donor's infection responded to artemether-lumefantrine with parasites being cleared on day 3.", + "The blood donor had not displayed signs or symptoms of malaria.", + "The blood donor was screened for malaria on arrival in Sri Lanka.", + "The blood donor tested negative for malaria on both microscopy and RDT at the time of screening.", + "A blood smear examined microscopically at the point of blood donation was reported negative for malaria.", + "Retrospectively, the preserved smear of the donor's blood was found to contain P. falciparum parasites at a very low density.", + "The blood donor tested positive for malaria after the transfusion-induced case was diagnosed.", + "The blood donor was treated for malaria." + ] + }, + { + "id": "multiclinsum_test_2649_en.txt", + "fulltext": "This case report involves a 59-year-old female patient who, upon physical examination, exhibited spleen enlargement with occasional left low back pain as the only noticeable symptom. The CT scan indicates a low-density mass in the spleen , measuring 41mm in diameter. During the enhancement scan, there is mild and sustained enhancement in each phase, with clear margins. Within the mass, lower-density foci are observable, lacking apparent enhancement. Radiologically, there is a suspicion of sclerosing angiomatoid nodular transformation (SANT) in the spleen. Moreover, no abnormal serum tumor markers were found in this patient. Finally, the patient underwent a partial splenectomy. Macroscopic examination revealed a protruding gray-yellow mass beneath the splenic capsule, measuring 4.5cm×4cm×3cm. The cut surface of the mass exhibited a soft, friable texture, with well-defined boundaries against the surrounding tissues.\nUnder the microscope, the tumor exhibits relatively clear boundaries with surrounding tissues, lacking an apparent capsule. Within the tumor, there is a widespread distribution of non-caseating necrotizing granulomas . These granulomas consist of multinucleated giant cells and epithelioid cells, no evident necrosis identified. Interspersed between the granulomatous nodules, there is a significant infiltration of inflammatory cells, predominantly composed of plasma cells and lymphocytes, with the absence of lymphoid follicle formation. In the prominent inflammatory cellular background, spindle or oval-shaped cells are observed. At high magnification, the boundaries between these spindle cells appear indistinct, with a relatively sparse arrangement. The tumor cells exhibit mild cytologic atypia, with chromatin showing a pale affinity for eosin staining. The nuclear shape varies from round to spindle, accompanied by smooth nuclear membranes and conspicuous small nucleoli. Mitotic figures are rarely observed .\nImmunohistochemical staining further revealed that the spindle cells were positive for CD21 and CD23 , while S-100 and SMA demonstrated partial positivity. Desmin, ALK and CKpan, however, were all negative. In the inflammatory stroma, diffuse expanses of CD38-positive plasma cells and CD68-positive tissue cells are evident. Lymphocytes are predominantly composed of CD3-expressing T cells, with localized presence of CD20-positive B cells. Notably, a minimal proportion of plasma cells exhibited positivity for IgG4. The proliferation index of fat fusiform cells, measured by Ki-67, was approximately 15%. Furthermore, Epstein-Barr encoding region (EBER) in situ hybridization confirmed the presence of positive signals for EBV, while acid-fast staining yielded negative results in tumor cells .\nCombined with morphology and immunohistochemistry, the final pathological diagnosis of this case was EBV+IFDCS. As of the submission of this case, the patient is still alive.", + "fulltext_subclaims": [ + "The patient is a 59-year-old female.", + "The patient exhibited spleen enlargement.", + "The CT scan indicates a low-density mass in the spleen.", + "The mass measured 41mm in diameter.", + "During the enhancement scan, there is mild and sustained enhancement in each phase.", + "The mass has clear margins.", + "Lower-density foci are observable within the mass.", + "The lower-density foci lack apparent enhancement.", + "Radiologically, there is a suspicion of sclerosing angiomatoid nodular transformation (SANT) in the spleen.", + "No abnormal serum tumor markers were found.", + "The patient underwent a partial splenectomy.", + "Macroscopic examination revealed a protruding gray-yellow mass beneath the splenic capsule.", + "The mass measured 4.5cm×4cm×3cm.", + "The cut surface of the mass exhibited a soft, friable texture.", + "The mass had well-defined boundaries against the surrounding tissues.", + "The tumor exhibits relatively clear boundaries with surrounding tissues.", + "The tumor lacks an apparent capsule.", + "There is a widespread distribution of non-caseating necrotizing granulomas within the tumor.", + "The granulomas consist of multinucleated giant cells and epithelioid cells.", + "No evident necrosis was identified.", + "There is a significant infiltration of inflammatory cells between the granulomatous nodules.", + "The inflammatory cells are predominantly composed of plasma cells and lymphocytes.", + "There is no lymphoid follicle formation.", + "Spindle or oval-shaped cells are observed in the inflammatory cellular background.", + "The boundaries between the spindle cells appear indistinct at high magnification.", + "The spindle cells have a relatively sparse arrangement.", + "The tumor cells exhibit mild cytologic atypia.", + "The chromatin shows a pale affinity for eosin staining.", + "The nuclear shape varies from round to spindle.", + "The nuclear membranes are smooth.", + "The nucleoli are conspicuous and small.", + "Mitotic figures are rarely observed.", + "The spindle cells were positive for CD21.", + "The spindle cells were positive for CD23.", + "S-100 demonstrated partial positivity.", + "SMA demonstrated partial positivity.", + "Desmin was negative.", + "ALK was negative.", + "CKpan was negative.", + "CD38-positive plasma cells are evident in the inflammatory stroma.", + "CD68-positive tissue cells are evident in the inflammatory stroma.", + "Lymphocytes are predominantly composed of CD3-expressing T cells.", + "Localized presence of CD20-positive B cells is observed.", + "A minimal proportion of plasma cells exhibited positivity for IgG4.", + "The proliferation index of fat fusiform cells, measured by Ki-67, was approximately 15%.", + "EBER in situ hybridization confirmed the presence of positive signals for EBV.", + "Acid-fast staining yielded negative results in tumor cells.", + "The final pathological diagnosis was EBV+IFDCS.", + "The patient is still alive." + ], + "summary": "A 59-year-old female, with no significant discomfort, was found to have a splenic mass during a routine physical examination. Microscopic examination at low magnification revealed numerous epithelioid granulomas, amidst which a substantial inflammatory response was observed. Interspersed among the dense inflammatory cells were spindle or oval-shaped cells, distributed sporadically with indistinct boundaries. Under high magnification, these spindle cells had subtle features: smooth and clear nuclear membranes, inconspicuous small nucleoli, and infrequent mitotic figures. Immunophenotypically, the spindle cells expressed CD21 and CD23, and Epstein-Barr encoding region (EBER) in situ hybridization yielded positive results. The inflammatory milieu predominantly consisted of T cells, with a minority of plasma cells expressing IgG4. The confluence of morphological and immunohistochemical findings led to the final pathological diagnosis of EBV+IFDCS in this case.", + "summary_subclaims": [ + "The patient is a 59-year-old female.", + "The patient had no significant discomfort.", + "A splenic mass was found during a routine physical examination.", + "Microscopic examination at low magnification revealed numerous epithelioid granulomas.", + "A substantial inflammatory response was observed.", + "Spindle or oval-shaped cells were interspersed among the dense inflammatory cells.", + "The spindle cells were distributed sporadically with indistinct boundaries.", + "Under high magnification, the spindle cells had smooth and clear nuclear membranes.", + "The spindle cells had inconspicuous small nucleoli.", + "Mitotic figures were infrequent.", + "The spindle cells expressed CD21.", + "The spindle cells expressed CD23.", + "Epstein-Barr encoding region (EBER) in situ hybridization yielded positive results.", + "The inflammatory milieu predominantly consisted of T cells.", + "A minority of plasma cells expressed IgG4.", + "The final pathological diagnosis was EBV+IFDCS." + ] + }, + { + "id": "multiclinsum_test_2577_en.txt", + "fulltext": "A 26-year-old African American woman with accidental ankle subluxation presented to our emergency department with foot pain. As a part of her work-up, she was incidentally found to have an elevated serum creatinine level of 2.2 mg/dL and proteinuria. Therefore, our patient was referred to a nephrologist for further evaluation.\nHer medical history included morbid obesity, hypertension, and hyperlipidemia. The hypertension had been present for 5 years, and was controlled with metoprolol (25 mg, twice a day) and amlodipine (10 mg, daily). Her other medications included ranitidine (150 mg, daily), lovastatin (20 mg, daily) and norgestimate ethinyl estradiol (one tablet, daily). Moreover, she took ibuprofen once a month, as needed, for shoulder pain. We did not note any personal or family history of kidney disease, autoimmune disease, or diabetes. The results of her physical examination were relatively unremarkable, except for obesity and moderate edema limited to her lower extremities. Her blood pressure was 140/90 mmHg. Examination of a 24-hour urine collection showed 11 g of urinary protein and hematuria. Her serum albumin level was 1.8 g/dL.\nA kidney ultrasonography indicated normal size kidneys. Thereafter, she underwent a kidney biopsy, which showed severe noncaseating epithelioid granulomatous necrotizing interstitial nephritis, necrotizing vascular lesion , and cellular crescent formation that were related to the underlying sarcoidosis. Immunofluorescence studies were negative for immunoglobulin (Ig) IgA, IgM, kappa, lambda, C1q, C3, and fibrinogen but mild diffuse linear glomerular capillary staining for IgG was suggestive of pauci-immune crescentic glomerulonephritis.\nElectron microscopy revealed no immune complex deposits. Mycobacterium tuberculosis studies indicated negative results. Serologic testing showed normal complement levels and negative results for anti-nuclear antibody, double-stranded DNA, antineutrophil cytoplasmic antibody (ANCA), human immunodeficiency virus, Sjogren’s syndrome, rapid plasma reagin, and viral hepatitis. Urine protein electrophoresis showed nonselective proteinuria related to combined glomerular and tubular damage. Her level of rheumatoid factor was <3 units/mL. Moreover, she was found to have elevated levels of angiotensin converting enzyme of 78 U/L (normal, 16–68U/L), but her levels of calcium, vitamin D, and parathyroid hormone were normal. A subsequent computed tomography (CT) scan of her chest showed patchy ground-glass opacities within both the lower lobes, with multifocal air trapping, as well as mild thickening of the bronchioles and mild hilar fullness, consistent with stage II pulmonary sarcoidosis. CT of her abdomen showed diffuse pelvic, para-aortic, and mesenteric lymphadenopathy. Examination of a pelvic lymph node biopsy specimen demonstrated no evidence of any lymphoproliferative disorder. Flow cytometry reported a predominance of T-cells in the tissue, with a normal 3.9:1 ratio of CD4 and CD8. Her lactate dehydrogenase level was within normal limits. Childhood records indicated a history of bilateral uveitis, which was treated with prednisolone.\nOwing to the multisystem involvement, our patient was referred to a university-based sarcoidosis center. Because the renal pathology was predominant in her case, the management of immunosuppression was deferred to a nephrologist. She was initially treated with prednisone (60 mg, daily for 1 month), along with the subsequent addition of azathioprine (150 mg, daily). The prednisone administration was gradually tapered to 5 mg/day over 12 months. Subsequently, her nephrotic syndrome improved, her serum albumin levels improved to 3.8 g/dL, and her urinary protein levels markedly reduced from 11 g/24 hours to 1 g/24 hours. After 1 year, the concentration of interlukin-2 receptor in her peripheral blood was assessed, and the findings were suggestive of persistent disease activity. Hence, her azathioprine dose was increased to 200 mg/day.\nThirty months after diagnosis, our patient remains in partial renal remission, with stable stage 4 chronic kidney disease (creatinine, 2.5 mg/dL; glomerular filtration rate, 28 mL/min/1.73 m2) and minimal proteinuria.", + "fulltext_subclaims": [ + "The patient is a 26-year-old African American woman.", + "She had accidental ankle subluxation.", + "She presented to the emergency department with foot pain.", + "She was incidentally found to have an elevated serum creatinine level of 2.2 mg/dL.", + "She had proteinuria.", + "She was referred to a nephrologist.", + "Her medical history included morbid obesity.", + "Her medical history included hypertension.", + "Her medical history included hyperlipidemia.", + "Her hypertension was controlled with metoprolol 25 mg twice daily.", + "Her hypertension was controlled with amlodipine 10 mg daily.", + "She took ranitidine 150 mg daily.", + "She took lovastatin 20 mg daily.", + "She took norgestimate ethinyl estradiol one tablet daily.", + "She took ibuprofen once a month as needed for shoulder pain.", + "There was no personal or family history of kidney disease.", + "There was no personal or family history of autoimmune disease.", + "There was no personal or family history of diabetes.", + "Physical examination was unremarkable except for obesity and moderate lower extremity edema.", + "Her blood pressure was 140/90 mmHg.", + "A 24-hour urine collection showed 11 g of urinary protein.", + "A 24-hour urine collection showed hematuria.", + "Her serum albumin level was 1.8 g/dL.", + "Kidney ultrasonography showed normal size kidneys.", + "A kidney biopsy showed severe noncaseating epithelioid granulomatous necrotizing interstitial nephritis.", + "A kidney biopsy showed necrotizing vascular lesion.", + "A kidney biopsy showed cellular crescent formation.", + "The renal pathology was related to the underlying sarcoidosis.", + "Immunofluorescence studies were negative for IgA.", + "Immunofluorescence studies were negative for IgM.", + "Immunofluorescence studies were negative for kappa.", + "Immunofluorescence studies were negative for lambda.", + "Immunofluorescence studies were negative for C1q.", + "Immunofluorescence studies were negative for C3.", + "Immunofluorescence studies were negative for fibrinogen.", + "Immunofluorescence studies showed mild diffuse linear glomerular capillary staining for IgG.", + "The IgG staining was suggestive of pauci-immune crescentic glomerulonephritis.", + "Electron microscopy revealed no immune complex deposits.", + "Mycobacterium tuberculosis studies were negative.", + "Serologic testing showed normal complement levels.", + "Serologic testing showed negative results for anti-nuclear antibody.", + "Serologic testing showed negative results for double-stranded DNA.", + "Serologic testing showed negative results for ANCA.", + "Serologic testing showed negative results for HIV.", + "Serologic testing showed negative results for Sjogren’s syndrome.", + "Serologic testing showed negative results for rapid plasma reagin.", + "Serologic testing showed negative results for viral hepatitis.", + "Urine protein electrophoresis showed nonselective proteinuria.", + "The nonselective proteinuria was related to combined glomerular and tubular damage.", + "Her rheumatoid factor level was <3 units/mL.", + "Her angiotensin converting enzyme level was 78 U/L.", + "The normal range for angiotensin converting enzyme is 16–68 U/L.", + "A CT scan of the chest showed patchy ground-glass opacities in both lower lobes.", + "A CT scan showed multifocal air trapping.", + "A CT scan showed mild thickening of the bronchioles.", + "A CT scan showed mild hilar fullness.", + "The CT findings were consistent with stage II pulmonary sarcoidosis.", + "A CT scan of the abdomen showed diffuse pelvic, para-aortic, and mesenteric lymphadenopathy.", + "A pelvic lymph node biopsy showed no evidence of lymphoproliferative disorder.", + "Flow cytometry reported a predominance of T-cells in the tissue.", + "The CD4:CD8 ratio was 3.9:1.", + "Her lactate dehydrogenase level was within normal limits.", + "Childhood records indicated a history of bilateral uveitis.", + "The uveitis was treated with prednisolone.", + "She was referred to a university-based sarcoidosis center.", + "The management of immunosuppression was deferred to a nephrologist.", + "She was initially treated with prednisone 60 mg daily for 1 month.", + "Azathioprine 150 mg daily was added after prednisone.", + "Prednisone was tapered to 5 mg/day over 12 months.", + "Her nephrotic syndrome improved.", + "Her serum albumin improved to 3.8 g/dL.", + "Urinary protein levels reduced from 11 g/24 hours to 1 g/24 hours.", + "After 1 year, interlukin-2 receptor concentration was assessed.", + "The findings were suggestive of persistent disease activity.", + "Her azathioprine dose was increased to 200 mg/day.", + "Thirty months after diagnosis, she remained in partial renal remission.", + "She had stable stage 4 chronic kidney disease.", + "Her creatinine was 2.5 mg/dL.", + "Her glomerular filtration rate was 28 mL/min/1.73 m2.", + "She had minimal proteinuria." + ], + "summary": "We describe the case of a 26-year-old African American woman with systemic sarcoidosis, with a unique constellation of renal lesions, including noncaseating epithelioid granulomatous necrotizing interstitial nephritis, cellular crescent formation, and necrotizing vasculitis. Immunosuppressive therapy was helpful for alleviating her nephrotic syndrome and maintaining the stability of her renal function over a 30-month period.", + "summary_subclaims": [ + "The patient is a 26-year-old African American woman.", + "The patient has systemic sarcoidosis.", + "The patient had noncaseating epithelioid granulomatous necrotizing interstitial nephritis.", + "The patient had cellular crescent formation.", + "The patient had necrotizing vasculitis.", + "Immunosuppressive therapy was helpful for alleviating her nephrotic syndrome.", + "Immunosuppressive therapy helped maintain the stability of her renal function over a 30-month period." + ] + }, + { + "id": "multiclinsum_test_198_en.txt", + "fulltext": "A 32 year old Korean woman presented with a one week history of right ocular surface discomfort, and the sudden appearance of a firm cystic lesion fixed to the palpebral conjunctiva of her right lower eyelid by a central trunk . The lesion was non-tender, had never ulcerated or haemorrhaged, and was increasing in size daily. At presentation, its dimensions were 5 mm × 7 mm × 3 mm. A history of bilateral epiblepharon correction performed in Korea three months prior was given. The patient was systemically well, and had no other significant ocular or medical history. Her uncorrected visual acuity was 6/5 bilaterally. Extraocular movements were full and painless. Bilateral anterior segment and dilated fundus examinations were unremarkable. The lesion was completely excised at the trunk under local anaesthesia with minimal bleeding. Chloramphenicol ointment QID OD was commenced post-operatively for one week. There were no signs of recurrence one week post-excision. Histopathology demonstrated a central zone of myxoid change (containing spindle-cells, stellate-cells, sparse blood vessels, and patchy inflammation), surrounded by a zone of fibrous connective tissue . Alcian blue staining was positive for connective tissue mucin . Digested Periodic-acid-Schiff (PAS) staining was negative for epithelial mucin. Complete systemic evaluation excluded any further myxomas (including cardiac), unusual areas of pigmentation, and endocrine abnormalities.\nConjunctival myxomas are rare. Grossniklaus et al. (1987) noted four cases of conjunctival myxoma in a review of 2455 conjunctival specimens [, ]. Similarly, Shields et al. (2004) reported one case of conjunctival myxoma in a clinical review of 1643 conjunctival lesions [, ]. Including this case, the mean age at presentation is 45 years [–]. A review of 58 patients with myxomas in other soft tissues found the mean age to be 55 years . No significant trends in gender or racial predisposition have been noted to date, however the number of reported cases remains small [, ].\nConjunctival myxomas typically present as slow-growing, painless, well circumscribed, yellow-pink, cyst-like masses, with fibrous, vascular, soft tissue trunks [–]. Not including this case, the mean timeframe before patients presented for ophthalmic review of their conjunctival myxoma was 34 months . This patient’s conjunctival myxoma developed rapidly over one week to a 5 mm × 7 mm × 3mm lesion. Lesions have been reported to range between 4 mm and 20 mm in diameter . This lesion reached almost half the recorded maximum size within one week. The majority of cases are painless –although there have been two reported cases of conjunctival myxoma with ocular pain . Ninety percent of reported conjunctival myxomas occurred in the bulbar conjunctiva - with the majority being temporal . This is the second case to be documented as arising from the inferior palpebral conjunctiva . There have been no previous reports of conjunctival myxoma developing within close proximity to trauma or ophthalmic surgery [, , , ]. This patient presented with her myxoma within 3 months of having bilateral uncomplicated surgical correction of her congenital epiblepharon - a common occurrence in Asians . We could not determine any connection between her bilateral congenital epiblepharon and conjunctival myxoma. The conjunctival myxoma in this case had a typical clinical appearance. It was atypical because of its rapid growth rate, its unusual location on the inferior palpebral conjunctiva, and its occurrence in association with recent eyelid surgery.\nHistologically, myxomas resemble Wharton’s jelly, the loose mucoid tissue found within the umbilical cord [, ]. The characteristic histopathological features of conjunctival myxoma are, sparsely scattered stellate- and spindle-shaped cells distributed throughout a mucinous matrix, with delicate reticulin fibres, minimal blood vessels, and mature collagen fibres [, , , , ]. The mucinous matrix is predominantly composed of hyaluronic acid, with a lesser amount of chondroitin sulphate, and has been reported to react to vimentin, Alcian blue, and alpha-smooth-muscle actin staining, suggesting a fibroblastic cell phenotype [, , ]. It is non-reactive to S-100 protein, desmin, myoglobulin, and digested Periodic-acid-Schiff (PAS) staining [, ]. The differential diagnosis of conjunctival myxomas includes, amelanotic naevus, amelanotic melanoma, fibrous histiocytoma, conjunctival cyst, lymphangioma, myxoid neurofibroma, spindle-cell lipoma, rhabdomyosarcoma, and liposarcoma [–]. Histologically, an absence of pigmentation, the presence of sparse vascular structures, characteristic cellular morphology, and mucin staining, help differentiate conjunctival myxomas from these lesions .\nTo date all cases of conjunctival myxoma have been treated with excisional biopsy [, ]. There have been no previous reports of malignant transformation in a mean follow-up time of 30 months (range 5–132 months) [, , ]. There has only been one reported case of recurrence, which occurred 12 months after the original excision in a patient with the Carney Complex . In general, the recurrence rate of all myxomas is documented as being relatively low. A review of 58 patients with soft tissue myxomas found a 3 % incidence of recurrence 8–10 months post-excision .\nConjunctival myxoma has been associated with both the Carney Complex and Zollinger-Ellison syndrome [, , ]. The Carney Complex is an autosomal dominant syndrome that requires at least two of the following criteria for diagnosis: the presence of myxomas; spotty mucocutaneous pigmentation (face, trunk, lips, eyelid, conjunctiva); endocrine overactivity (Cushing’s syndrome, pituitary adenoma, and/or sexual precocity); or psammomatous melanotic schwannomas [, , ]. Ophthalmic manifestations of the Carney Complex include eyelid lentigines, conjunctival or caruncle spotty pigmentation, and eyelid or conjunctival myxomas [, ]. The one case of conjunctival myxoma associated with the Carney Complex exhibited palpebral conjunctival, eyelid, coetaneous, and left ventricular myxomas . Carney reported that greater than 50 % of patients with the Carney Complex suffered a significant embolic event in their lifetime related to cardiac myxomas . Ophthalmic manifestations of the Carney Complex, not limited to myxoma, have been shown to precede embolic events [, ]. Early identification of ocular myxomas and subsequent screening and monitoring for cardiac myxoma is recommended.\nConjunctival myxoma has been associated with a case of pancreatic gastrinoma in Zollinger-Ellison syndrome . Zollinger-Ellison syndrome may be a manifestation of the Carney Complex, given the neural crest origins of myxomas, schwannomas (seen in the Carney Complex), and gastrinomas . Conjunctival myxomas have not been reported with other systemic diseases associated with myxomas, such as Mazabraud syndrome (intramuscular myxoma) and McCune-Albright syndrome (intramuscular and coetaneous) [, ].", + "fulltext_subclaims": [ + "The patient was a 32 year old Korean woman.", + "She had a one week history of right ocular surface discomfort.", + "A firm cystic lesion was fixed to the palpebral conjunctiva of her right lower eyelid by a central trunk.", + "The lesion was non-tender.", + "The lesion had never ulcerated or haemorrhaged.", + "The lesion was increasing in size daily.", + "At presentation, the lesion was 5 mm × 7 mm × 3 mm.", + "The patient had a history of bilateral epiblepharon correction performed in Korea three months prior.", + "The patient was systemically well.", + "Her uncorrected visual acuity was 6/5 bilaterally.", + "Extraocular movements were full and painless.", + "Bilateral anterior segment and dilated fundus examinations were unremarkable.", + "The lesion was completely excised at the trunk under local anaesthesia with minimal bleeding.", + "Chloramphenicol ointment QID OD was commenced post-operatively for one week.", + "There were no signs of recurrence one week post-excision.", + "Histopathology demonstrated a central zone of myxoid change.", + "Alcian blue staining was positive for connective tissue mucin.", + "Digested Periodic-acid-Schiff (PAS) staining was negative for epithelial mucin.", + "Complete systemic evaluation excluded any further myxomas.", + "Complete systemic evaluation excluded unusual areas of pigmentation.", + "Complete systemic evaluation excluded endocrine abnormalities.", + "Conjunctival myxomas are rare.", + "Grossniklaus et al. (1987) noted four cases of conjunctival myxoma in a review of 2455 conjunctival specimens.", + "Shields et al. (2004) reported one case of conjunctival myxoma in a clinical review of 1643 conjunctival lesions.", + "Including this case, the mean age at presentation is 45 years.", + "A review of 58 patients with myxomas in other soft tissues found the mean age to be 55 years.", + "No significant trends in gender or racial predisposition have been noted to date.", + "The number of reported cases remains small.", + "Conjunctival myxomas typically present as slow-growing, painless, well circumscribed, yellow-pink, cyst-like masses.", + "The mean timeframe before patients presented for ophthalmic review of their conjunctival myxoma was 34 months.", + "This patient’s conjunctival myxoma developed rapidly over one week to a 5 mm × 7 mm × 3 mm lesion.", + "Lesions have been reported to range between 4 mm and 20 mm in diameter.", + "This lesion reached almost half the recorded maximum size within one week.", + "The majority of cases are painless.", + "There have been two reported cases of conjunctival myxoma with ocular pain.", + "Ninety percent of reported conjunctival myxomas occurred in the bulbar conjunctiva.", + "The majority of bulbar conjunctival myxomas are temporal.", + "This is the second case to be documented as arising from the inferior palpebral conjunctiva.", + "There have been no previous reports of conjunctival myxoma developing within close proximity to trauma or ophthalmic surgery.", + "This patient presented with her myxoma within 3 months of having bilateral uncomplicated surgical correction of her congenital epiblepharon.", + "We could not determine any connection between her bilateral congenital epiblepharon and conjunctival myxoma.", + "The conjunctival myxoma in this case had a typical clinical appearance.", + "It was atypical because of its rapid growth rate.", + "It was atypical because of its unusual location on the inferior palpebral conjunctiva.", + "It was atypical because of its occurrence in association with recent eyelid surgery.", + "Histologically, myxomas resemble Wharton’s jelly.", + "The characteristic histopathological features of conjunctival myxoma are sparsely scattered stellate- and spindle-shaped cells distributed throughout a mucinous matrix.", + "The mucinous matrix is predominantly composed of hyaluronic acid.", + "The mucinous matrix has been reported to react to vimentin, Alcian blue, and alpha-smooth-muscle actin staining.", + "It is non-reactive to S-100 protein, desmin, myoglobulin, and digested Periodic-acid-Schiff (PAS) staining.", + "The differential diagnosis of conjunctival myxomas includes amelanotic naevus, amelanotic melanoma, fibrous histiocytoma, conjunctival cyst, lymphangioma, myxoid neurofibroma, spindle-cell lipoma, rhabdomyosarcoma, and liposarcoma.", + "An absence of pigmentation helps differentiate conjunctival myxomas from these lesions.", + "The presence of sparse vascular structures helps differentiate conjunctival myxomas from these lesions.", + "Characteristic cellular morphology helps differentiate conjunctival myxomas from these lesions.", + "Mucin staining helps differentiate conjunctival myxomas from these lesions.", + "To date all cases of conjunctival myxoma have been treated with excisional biopsy.", + "There have been no previous reports of malignant transformation in a mean follow-up time of 30 months.", + "There has only been one reported case of recurrence, which occurred 12 months after the original excision in a patient with the Carney Complex.", + "The recurrence rate of all myxomas is documented as being relatively low.", + "A review of 58 patients with soft tissue myxomas found a 3 % incidence of recurrence 8–10 months post-excision.", + "Conjunctival myxoma has been associated with both the Carney Complex and Zollinger-Ellison syndrome.", + "The Carney Complex is an autosomal dominant syndrome.", + "The Carney Complex requires at least two of the following criteria for diagnosis: the presence of myxomas; spotty mucocutaneous pigmentation; endocrine overactivity; or psammomatous melanotic schwannomas.", + "Ophthalmic manifestations of the Carney Complex include eyelid lentigines, conjunctival or caruncle spotty pigmentation, and eyelid or conjunctival myxomas.", + "The one case of conjunctival myxoma associated with the Carney Complex exhibited palpebral conjunctival, eyelid, coetaneous, and left ventricular myxomas.", + "Carney reported that greater than 50 % of patients with the Carney Complex suffered a significant embolic event in their lifetime related to cardiac myxomas.", + "Ophthalmic manifestations of the Carney Complex, not limited to myxoma, have been shown to precede embolic events.", + "Early identification of ocular myxomas and subsequent screening and monitoring for cardiac myxoma is recommended.", + "Conjunctival myxoma has been associated with a case of pancreatic gastrinoma in Zollinger-Ellison syndrome.", + "Zollinger-Ellison syndrome may be a manifestation of the Carney Complex.", + "Conjunctival myxomas have not been reported with other systemic diseases associated with myxomas, such as Mazabraud syndrome and McCune-Albright syndrome." + ], + "summary": "A 32 year old Korean woman presented with a 5 mm × 7 mm × 3 mm pedunculated firm cystic lesion on the inferior palpebral conjunctiva of her right lower eyelid. The lesion had rapidly enlarged over the course of a week. She gave a history of uncomplicated bilateral epiblepharon correction performed in Korea three months prior. There were no systemic features, or family history of genetic conditions. The lesion was excised under local anaesthesia and reported to be a conjunctival myxoma. The clinical and histopathological features of this lesion were consistent with previous reports on conjunctival myxoma (Arch Ophthalmol 124:735-8, 2006; Arch Ophthalmol 101:1416-20, 1983; Case Rep Ophthalmol 3:145-50, 2012; Am J Ophthalmol 102(1):80-84, 1986). The unusual features of this case were, the rapid growth of the lesion - with the previously documented mean time before presentation being 34 months (range 3 months - 24 years) (Arch Ophthalmol 124:735-8, 2006; Case Rep Ophthalmol 3:145-50, 2012); the location of the lesion in the inferior palpebral conjunctiva - 93 % of previously reported cases had occurred in the bulbar conjunctiva (Arch Ophthalmol 124:735-8, 2006; Case Rep Ophthalmol 3:145-50, 2012); and its occurrence in association with recent eyelid surgery - which has never been reported.", + "summary_subclaims": [ + "The patient is a 32 year old Korean woman.", + "The lesion was a 5 mm × 7 mm × 3 mm pedunculated firm cystic lesion.", + "The lesion was located on the inferior palpebral conjunctiva of the right lower eyelid.", + "The lesion had rapidly enlarged over the course of a week.", + "The patient had a history of uncomplicated bilateral epiblepharon correction performed in Korea three months prior.", + "The lesion was excised under local anaesthesia.", + "The lesion was reported to be a conjunctival myxoma.", + "The clinical and histopathological features of this lesion were consistent with previous reports on conjunctival myxoma.", + "The previously documented mean time before presentation was 34 months.", + "The previously documented range before presentation was 3 months to 24 years.", + "93% of previously reported cases had occurred in the bulbar conjunctiva.", + "The lesion's occurrence in association with recent eyelid surgery has never been reported." + ] + }, + { + "id": "multiclinsum_test_3297_en.txt", + "fulltext": "We admitted a child of 3 years and 11 months to the pediatric intensive care unit (PICU) of Montpellier University Hospital following a sudden collapse at home.\n\nThe event occurred at about 1 pm, approximately 5 min after the child woke from a nap showing sudden eye rolling and loss of consciousness, but no abnormal movements. The father made the decision to transport her in his vehicle to the nearest medical center. Upon arrival 15 min later, the child was lifeless with cardiac asystole on electrocardiogram (ECG) and the medical team began cardiopulmonary resuscitation (CPR).\n\nAt admission, the child was pale and cold and showed no hematoma, purpura, rash or wound. Abundant digestive hemorrhage of black blood was aspirated by a gastric tube. Expired CO2 was very low, 20 mmHg, indicating prolonged low blood flow. ECG monitoring showed persistent asystole. After discussion with the referral service, there was no indication for circulatory extracorporeal membrane oxygenation. Resuscitation was stopped and death declared after 80 min of CPR performed by health professionals.\n\nThe parents were immediately interviewed and they asked for all exams, including an autopsy, to identify the cause of their child’s death. The forensic pathologist was contacted and, after being fully informed of all events prior to the child’s death, decided that an autopsy should be carried out, for both legal and medical purposes.\n\nThis girl was the first child of non-consanguineous Caucasian parents, born full-term with low weight for gestational age (2330 g at 39 weeks of gestation). She was without significant health problems and her vaccinations were up to date on her health record. The child had had gastroenteritis 3 weeks earlier. Two days before the event, she had a fever associated with fatigue and abdominal pain in the right iliac fossa. For this reason, she was kept at home and was examined by the general practitioner, who found no worrisome signs. Treatment with trimebutine maleate and domperidone was prescribed. The previous night, the father noted a small amount of vomiting and more frequent liquid intake. In the morning, she woke at 7 am with an occipital headache relieved with paracetamol. When she woke from her nap, she spoke correctly and had perioral cyanosis without any other sign of respiratory distress.\n\nAs for her family, her father had convulsions in childhood, from 6 months to 12 years, and was treated intermittently with diazepam. Her maternal great-grandmother died suddenly at the age of 25–35 years from a ruptured intracranial aneurysm.\n\nImmediately after death, transthoracic puncture in the cardiac area was performed to collect blood. The puncture, however, brought back 10 ml of yellow serous fluid, which prompted an echocardiography that revealed a large pericardial effusion. The analysis of the pericardial fluid was indicative of an exudate (albumin 46 g/L, protein 66.4 g/L, LDH 344 IU/L), with 440 cells/mm3 (73% granulocytes, 24% lymphocytes). Direct examination by Gram staining and bacterial culture was negative. The search for a panel of respiratory viruses by real-time polymerase chain reaction (PCR) was positive for respiratory syncytial virus (RSV).\n\nBacterial cultures of urine, cerebrospinal fluid (CSF) and blood were negative, and stool culture found neither fungal nor specific pathogenic bacteria, including clostridium botulinum. Bordetella pertussis and parapertussis were not found in nasal swabs. No other bacterial or viral analysis was performed on nasal specimens. The search for viruses in CSF, stool, and blood was also negative. Laboratory tests found normal concentrations for hemoglobin, C-reactive protein, and procalcitonin, while leukocyte (19.4 109/L) and platelet (448 109/L) counts were slightly elevated. The serum levels of immunoglobulins were normal for the age. Chromatography found no abnormal peak suggestive of aminoacidopathy, and the acylcarnitine profile was normal. No psychotropic or narcotic drugs were detected in the blood. Serum paracetamol concentration was within the therapeutic range (11.6 mg/L) but domperidone was undetectable. The carboxyhemoglobin level measured in the blood sample at admission was 0%. Radiography of the entire skeleton found no significant abnormality, including no recent or old fracture.\n\nThe autopsy was performed 48 h after death. External examination found normal development: weight 14.4 kg; height 100 cm. There was no morphological abnormality and no lesion suggestive of maltreatment or trauma. The internal examination found no malformation or visceral malposition. There was nonspecific polyvisceral congestion, as well as global cerebral edema without hemorrhage or mass effect, which could be attributed to the prolonged resuscitation. Several centimetric and infracentimetric flexible lymphadenopathies were observed at the cervical and mesenteric levels, which may be trivial at this age. The examination also confirmed a pericardial effusion of about 30 mL and bilateral pleural effusions of a few milliliters.\n\nPulmonary, hepatic and cardiac tissue fragments collected during autopsy were negative for a panel of viruses tested by PCR. Bacterial culture found postmortem contaminants, i.e., some lactococcus lactis in the liver and lungs, with klebsiella oxytoca after enrichment in the lung tissue.\n\nHistopathological examination of the tissues was normal except in the lungs and heart. Diffuse edematous lesions associated with severe alveolar hemorrhages were observed, particularly in the left lung. Rare foci of inflammatory interstitial lesions and discrete bronchitis lesions of the pedicular bronchi were also present in both lungs. Mild to moderate inflammatory infiltrate consisting of T lymphocytes and macrophages (respectively, about 7 per field and 9 per field under × 40 magnification) was found in the myocardium and epicardium, consistent with the diagnosis of myoepicarditis. Edematous foci and some myocyte changes were visualized. Immunolabeling with anti-CD3, −CD45 and -CD68 antibodies highlighted the inflammatory infiltrates. Cardioneuropathy was also observed, with embracing and sometimes penetration of autonomic nerves and ganglion cells by inflammatory cells.\n\nA joint consultation, in the presence of a pediatrician and psychologist, was held with the parents 7 weeks after the death of their daughter. The parents were told that the most likely cause of death appeared to be a cardiac rhythm disorder occurring in the context of myocardial inflammation. Five months after this first consultation, a new meeting with the family was requested because we had just received the molecular analysis of unexplained sudden death genes on an index case. Among a panel of 31 genes, a heterozygous variation was identified in exon 6 of the myosin light chain 2 (MYL2) gene, responsible for the replacement of a glutamic acid by alanine at position 134 p and probably corresponding to a pathogenic variant (class 4 of pathogenicity). At this meeting, we thus proposed a family study to investigate the segregation of this variant with the phenotype and to determine its deleteriousness. Their 20-month-old son was examined by a pediatric cardiologist. Clinical examination was normal, with easily palpated axillary and femoral pulses, normal blood pressure and absence of cardiac murmur. ECG showed a regular sinus rhythm at 126 bpm and conduction and repolarization normal for age. Echocardiography found normal intracardiac architecture, good biventricular function, and the absence of any sign suggestive of cardiomyopathy, valvulopathy or pulmonary arterial hypertension. Molecular analysis of the MYL2 gene, however, revealed the same heterozygous variation as in his sister. The parents were also examined by an adult cardiologist. ECG and echocardiography were normal for both. The mutation in the MYL2 gene was observed in the father only.\n\nThese elements prompted a new reading of the cardiac histology by two anatomopathologists in two different laboratories, both of whom reported no evidence of arrhythmogenic right ventricular dysplasia or hypertrophic cardiomyopathy (HCM).", + "fulltext_subclaims": [ + "The child was a 3-year-11-month-old girl.", + "She was admitted to the pediatric intensive care unit of Montpellier University Hospital after a sudden collapse at home.", + "The event occurred at about 1 pm, approximately 5 min after the child woke from a nap.", + "The child showed sudden eye rolling and loss of consciousness, but no abnormal movements.", + "The father transported her to the nearest medical center in his vehicle.", + "Upon arrival 15 min later, the child was lifeless with cardiac asystole on electrocardiogram.", + "The medical team began cardiopulmonary resuscitation.", + "At admission, the child was pale and cold.", + "There was no hematoma, purpura, rash, or wound.", + "Abundant digestive hemorrhage of black blood was aspirated by a gastric tube.", + "Expired CO2 was very low, 20 mmHg.", + "ECG monitoring showed persistent asystole.", + "There was no indication for circulatory extracorporeal membrane oxygenation.", + "Resuscitation was stopped and death declared after 80 min of CPR performed by health professionals.", + "The parents asked for all exams, including an autopsy, to identify the cause of their child’s death.", + "The forensic pathologist decided that an autopsy should be carried out.", + "The girl was the first child of non-consanguineous Caucasian parents.", + "She was born full-term with low weight for gestational age (2330 g at 39 weeks of gestation).", + "She had no significant health problems.", + "Her vaccinations were up to date.", + "She had had gastroenteritis 3 weeks earlier.", + "Two days before the event, she had a fever associated with fatigue and abdominal pain in the right iliac fossa.", + "She was examined by the general practitioner, who found no worrisome signs.", + "Treatment with trimebutine maleate and domperidone was prescribed.", + "The previous night, the father noted a small amount of vomiting.", + "In the morning, she woke at 7 am with an occipital headache relieved with paracetamol.", + "When she woke from her nap, she spoke correctly and had perioral cyanosis without any other sign of respiratory distress.", + "Her father had convulsions in childhood, from 6 months to 12 years.", + "Her maternal great-grandmother died suddenly at the age of 25–35 years from a ruptured intracranial aneurysm.", + "Transthoracic puncture in the cardiac area was performed to collect blood.", + "The puncture brought back 10 ml of yellow serous fluid.", + "Echocardiography revealed a large pericardial effusion.", + "The analysis of the pericardial fluid was indicative of an exudate.", + "Direct examination by Gram staining and bacterial culture was negative.", + "The search for a panel of respiratory viruses by real-time polymerase chain reaction was positive for respiratory syncytial virus.", + "Bacterial cultures of urine, cerebrospinal fluid, and blood were negative.", + "Stool culture found neither fungal nor specific pathogenic bacteria, including clostridium botulinum.", + "Bordetella pertussis and parapertussis were not found in nasal swabs.", + "No other bacterial or viral analysis was performed on nasal specimens.", + "The search for viruses in CSF, stool, and blood was also negative.", + "Laboratory tests found normal concentrations for hemoglobin, C-reactive protein, and procalcitonin.", + "Leukocyte count was slightly elevated.", + "Platelet count was slightly elevated.", + "The serum levels of immunoglobulins were normal for the age.", + "Chromatography found no abnormal peak suggestive of aminoacidopathy.", + "The acylcarnitine profile was normal.", + "No psychotropic or narcotic drugs were detected in the blood.", + "Serum paracetamol concentration was within the therapeutic range.", + "Domperidone was undetectable.", + "The carboxyhemoglobin level measured in the blood sample at admission was 0%.", + "Radiography of the entire skeleton found no significant abnormality.", + "The autopsy was performed 48 h after death.", + "External examination found normal development.", + "There was no morphological abnormality.", + "There was no lesion suggestive of maltreatment or trauma.", + "The internal examination found no malformation or visceral malposition.", + "There was nonspecific polyvisceral congestion.", + "There was global cerebral edema without hemorrhage or mass effect.", + "Several centimetric and infracentimetric flexible lymphadenopathies were observed at the cervical and mesenteric levels.", + "The examination confirmed a pericardial effusion of about 30 mL.", + "Bilateral pleural effusions of a few milliliters were observed.", + "Pulmonary, hepatic, and cardiac tissue fragments collected during autopsy were negative for a panel of viruses tested by PCR.", + "Bacterial culture found postmortem contaminants.", + "Histopathological examination of the tissues was normal except in the lungs and heart.", + "Diffuse edematous lesions associated with severe alveolar hemorrhages were observed, particularly in the left lung.", + "Rare foci of inflammatory interstitial lesions and discrete bronchitis lesions of the pedicular bronchi were also present in both lungs.", + "Mild to moderate inflammatory infiltrate consisting of T lymphocytes and macrophages was found in the myocardium and epicardium.", + "The inflammatory infiltrates were consistent with the diagnosis of myoepicarditis.", + "Edematous foci and some myocyte changes were visualized.", + "Immunolabeling with anti-CD3, −CD45, and -CD68 antibodies highlighted the inflammatory infiltrates.", + "Cardioneuropathy was also observed.", + "A joint consultation was held with the parents 7 weeks after the death of their daughter.", + "The parents were told that the most likely cause of death appeared to be a cardiac rhythm disorder occurring in the context of myocardial inflammation.", + "A new meeting with the family was requested five months after the first consultation.", + "A heterozygous variation was identified in exon 6 of the myosin light chain 2 (MYL2) gene.", + "The variation was responsible for the replacement of a glutamic acid by alanine at position 134 p.", + "The variation was probably corresponding to a pathogenic variant (class 4 of pathogenicity).", + "A family study was proposed to investigate the segregation of this variant with the phenotype and to determine its deleteriousness.", + "Their 20-month-old son was examined by a pediatric cardiologist.", + "Clinical examination was normal.", + "ECG showed a regular sinus rhythm at 126 bpm.", + "Echocardiography found normal intracardiac architecture.", + "Molecular analysis of the MYL2 gene revealed the same heterozygous variation as in his sister.", + "The parents were also examined by an adult cardiologist.", + "The mutation in the MYL2 gene was observed in the father only.", + "Two anatomopathologists reported no evidence of arrhythmogenic right ventricular dysplasia or hypertrophic cardiomyopathy." + ], + "summary": "A 47-month-old girl was admitted to the pediatric intensive care unit following sudden cardiopulmonary arrest occurring at home. The electrocardiogram showed cardiac asystole, which was refractory to prolonged resuscitation efforts. Postmortem analyses detected RSV by polymerase chain reaction in an abundant, exudative pericardial effusion. Histopathological examination was consistent with viral myoepicarditis, including an inflammatory process affecting cardiac nerves and ganglia. Molecular analysis of sudden unexplained death genes identified a heterozygous mutation in myosin light chain 2, which was also found in two other healthy members of the family. Additional expert interpretation of the cardiac histology confirmed the absence of arrhythmogenic right ventricular dysplasia or hypertrophic cardiomyopathy.", + "summary_subclaims": [ + "A 47-month-old girl was admitted to the pediatric intensive care unit following sudden cardiopulmonary arrest occurring at home.", + "The electrocardiogram showed cardiac asystole.", + "The cardiac asystole was refractory to prolonged resuscitation efforts.", + "Postmortem analyses detected RSV by polymerase chain reaction in an abundant, exudative pericardial effusion.", + "Histopathological examination was consistent with viral myoepicarditis.", + "The inflammatory process affected cardiac nerves and ganglia.", + "Molecular analysis of sudden unexplained death genes identified a heterozygous mutation in myosin light chain 2.", + "The heterozygous mutation in myosin light chain 2 was also found in two other healthy members of the family.", + "Expert interpretation of the cardiac histology confirmed the absence of arrhythmogenic right ventricular dysplasia.", + "Expert interpretation of the cardiac histology confirmed the absence of hypertrophic cardiomyopathy." + ] + }, + { + "id": "multiclinsum_test_1651_en.txt", + "fulltext": "An 83-year-old male patient had no family history of hypertension, chronic obstructive pulmonary disease, or malignancy. He smoked for 40 years and had a smoking index of 20 pack-years. He was admitted to the hospital for a physical examination, during which a chest computed tomography (CT) scan revealed a left hilar occupancy measuring approximately 5.9x3.6 cm, obstructive atelectasis in the left lung field, and a small pleural effusion. Further fiberoptic bronchoscopy revealed that the left main bronchus was blocked by new organisms, the surfaces of which oozed blood. This location was the site of the biopsy, which revealed lung squamous cell carcinoma . P40 (+), CK56 (-), ki-67 > 25%, TTF-1 (-) in immunohistochemistry. The patient ceased chemotherapy because he could not endure the adverse effects of nausea and vomiting after one cycle of perfusion chemotherapy (40 mg nedaplatin via bronchial artery infusion administration) and paclitaxel systemic intravenous treatment. After 7 months, the patient developed hemoptysis with a daily volume of about 10-20 mL, and chest CT scan revealed a left deviation of the mediastinum, left lung consolidation and atelectasis, a soft tissue mass in the left hilum with a size of about 8.1x4.6 cm, left main bronchial obstruction, and enlarged lymph nodes in the left cervical root and mediastinum. No obvious metastatic lesions had been found after head MRI, whole-body bone imaging, whole-abdomen enhancement CT. We took the disease’s progression into consideration (Clinical Stage, cT4N3M1a, stage IVA). Subsequently, the BRCA2 EXON15 G25085 mutation was detected by blood next-generation sequencing, and the tumor mutation load TMB was 5.98 mutations/Mb. Based on the sequencing test results, we immediately started aggressive treatment and decided to use the PARP inhibitor Olaparib (300mg twice a day) with the PD-1 inhibitor Cindilimab. After one week, the patient’s hemoptysis stopped. A repeat chest CT revealed that the left hilar mass was substantially smaller than before, with a long diameter of around 4.5 cm, and that the left lung was recruiting and the pleural effusion was absorbed after receiving Olaparib for two months and PD-1 inhibitor for two immunotherapy sessions. At this time, the patient appeared new symptoms, puffy eyelids, decreased urine volume, and generalized weakness. In further testing of common serological indicators, we found that blood creatinine increased from normal value at the beginning of the disease to 163.90μmol/L. Meanwhile, urine precipitation microscopy showed urine protein (+) without a tubular pattern. Routine blood, liver function, inflammation indicators, tumor indicators were normal, and autoantibodies were negative. Following the multidisciplinary team’s discussion, we took into account the kidney damage caused by immune checkpoint inhibitors, which was graded as 2, and stopped using the PD-1 inhibitor in accordance with the Chinese Society of Clinical Oncology (CSCO) 2022 recommendation. One month after quitting the PD-1 inhibitor, the serum creatinine level was back to normal. Six months after starting Olaparib monotherapy, the patient was more advanced. The therapy options, disease response, and PFS for each treatment line are summarized in .", + "fulltext_subclaims": [ + "The patient was an 83-year-old male.", + "The patient had no family history of hypertension.", + "The patient had no family history of chronic obstructive pulmonary disease.", + "The patient had no family history of malignancy.", + "The patient smoked for 40 years.", + "The patient had a smoking index of 20 pack-years.", + "A chest CT scan revealed a left hilar occupancy measuring approximately 5.9x3.6 cm.", + "A chest CT scan revealed obstructive atelectasis in the left lung field.", + "A chest CT scan revealed a small pleural effusion.", + "Fiberoptic bronchoscopy revealed that the left main bronchus was blocked by new organisms.", + "The surfaces of the new organisms oozed blood.", + "The biopsy revealed lung squamous cell carcinoma.", + "Immunohistochemistry showed P40 (+).", + "Immunohistochemistry showed CK56 (-).", + "Immunohistochemistry showed ki-67 > 25%.", + "Immunohistochemistry showed TTF-1 (-).", + "The patient ceased chemotherapy after one cycle.", + "The patient could not endure the adverse effects of nausea and vomiting.", + "The chemotherapy included 40 mg nedaplatin via bronchial artery infusion administration.", + "The chemotherapy included paclitaxel systemic intravenous treatment.", + "After 7 months, the patient developed hemoptysis with a daily volume of about 10-20 mL.", + "A chest CT scan revealed a left deviation of the mediastinum.", + "A chest CT scan revealed left lung consolidation and atelectasis.", + "A chest CT scan revealed a soft tissue mass in the left hilum with a size of about 8.1x4.6 cm.", + "A chest CT scan revealed left main bronchial obstruction.", + "A chest CT scan revealed enlarged lymph nodes in the left cervical root and mediastinum.", + "No obvious metastatic lesions had been found after head MRI.", + "No obvious metastatic lesions had been found after whole-body bone imaging.", + "No obvious metastatic lesions had been found after whole-abdomen enhancement CT.", + "The disease was considered to be progressing.", + "The clinical stage was cT4N3M1a.", + "The clinical stage was stage IVA.", + "The BRCA2 EXON15 G25085 mutation was detected by blood next-generation sequencing.", + "The tumor mutation load TMB was 5.98 mutations/Mb.", + "The treatment included the PARP inhibitor Olaparib (300mg twice a day).", + "The treatment included the PD-1 inhibitor Cindilimab.", + "After one week, the patient’s hemoptysis stopped.", + "A repeat chest CT revealed that the left hilar mass was substantially smaller than before.", + "The left hilar mass had a long diameter of around 4.5 cm.", + "The left lung was recruiting after receiving Olaparib for two months.", + "The pleural effusion was absorbed after receiving Olaparib for two months.", + "The patient received two immunotherapy sessions with the PD-1 inhibitor.", + "The patient developed new symptoms: puffy eyelids, decreased urine volume, and generalized weakness.", + "Blood creatinine increased to 163.90μmol/L.", + "Urine precipitation microscopy showed urine protein (+) without a tubular pattern.", + "Routine blood, liver function, inflammation indicators, tumor indicators were normal.", + "Autoantibodies were negative.", + "The multidisciplinary team took into account kidney damage caused by immune checkpoint inhibitors.", + "The kidney damage was graded as 2.", + "The PD-1 inhibitor was stopped in accordance with the CSCO 2022 recommendation.", + "One month after quitting the PD-1 inhibitor, the serum creatinine level was back to normal.", + "Six months after starting Olaparib monotherapy, the patient was more advanced." + ], + "summary": "In our study, we report a patient with advanced BRCA2 lung squamous cell carcinoma who received platinum-based chemotherapy combined with paclitaxel. Seven months later, the disease progressed. BRCA2 mutations were detected in peripheral blood by next-generation sequencing. After 2 months of treatment with Olaparib combined with Cindilimab, the patient was in partial remission and the progression-free survival (PFS) lasted for 6 months, but the patient developed immune renal damage.", + "summary_subclaims": [ + "The patient had advanced BRCA2 lung squamous cell carcinoma.", + "The patient received platinum-based chemotherapy combined with paclitaxel.", + "Seven months later, the disease progressed.", + "BRCA2 mutations were detected in peripheral blood by next-generation sequencing.", + "After 2 months of treatment with Olaparib combined with Cindilimab, the patient was in partial remission.", + "The progression-free survival lasted for 6 months.", + "The patient developed immune renal damage." + ] + }, + { + "id": "multiclinsum_test_561_en.txt", + "fulltext": "A 53-year-old male underwent a right L4-L5 microdiscectomy and foraminotomy and was discharged home the same day. With no improvement 6 months after surgery, we offered a trial of SCS, and he experienced significant relief from the back and leg pain. Ten days later, we placed an epidural paddle electrode through a T10–T11 laminotomy . The lead was secured to the ligamentum flavum with 4-0 NUROLON sutures. When he returned 15 days later, he no longer experienced pain relief and reported consistent stimulation in upper extremities. A thoracic X-ray revealed that the epidural paddle electrode had migrated to the cervical C6-C7 epidural space . Upon return to the operating room, we were able to retract the paddle electrode to the level of T5 where we encountered resistance; therefore, we performed a laminotomy at this level to remove the paddle electrode. When placing a new epidural paddle electrode, we encountered significant adhesions in the epidural space requiring additional laminotomies at T8–T9 and T9–T10 to adequately dissect the adhesions and place the epidural paddle electrode . We then affixed the leads to the T11 lamina using a 16 mm craniomaxillofacial low-profile plate. The patient was discharged home the following day without further sequelae.", + "fulltext_subclaims": [ + "The patient is a 53-year-old male.", + "The patient underwent a right L4-L5 microdiscectomy and foraminotomy.", + "The patient was discharged home the same day as the surgery.", + "Six months after surgery, the patient had no improvement.", + "A trial of SCS was offered.", + "The patient experienced significant relief from back and leg pain.", + "Ten days after the trial, an epidural paddle electrode was placed through a T10–T11 laminotomy.", + "The lead was secured to the ligamentum flavum with 4-0 NUROLON sutures.", + "Fifteen days after electrode placement, the patient no longer experienced pain relief.", + "The patient reported consistent stimulation in upper extremities.", + "A thoracic X-ray revealed that the epidural paddle electrode had migrated to the cervical C6-C7 epidural space.", + "The paddle electrode was retracted to the level of T5.", + "Resistance was encountered at T5.", + "A laminotomy was performed at T5 to remove the paddle electrode.", + "Significant adhesions were encountered in the epidural space.", + "Additional laminotomies were performed at T8–T9 and T9–T10.", + "The adhesions were dissected to place the epidural paddle electrode.", + "The leads were affixed to the T11 lamina using a 16 mm craniomaxillofacial low-profile plate.", + "The patient was discharged home the following day.", + "The patient had no further sequelae." + ], + "summary": "A 53-year-old male underwent uncomplicated spinal cord stimulator placement at the T10- T11 with initially favorable results. However, postoperatively, he complained of paresthesias in his arms. An X-ray demonstrated cranial migration of the thoracic epidural paddle to the cervical spine. The stimulator/new paddle was placed again at the T10-T11 level, but the leads were now secured to the caudal lamina utilizing a cranial plating system. The patient subsequently did well without further sequelae.", + "summary_subclaims": [ + "The patient is a 53-year-old male.", + "The patient underwent spinal cord stimulator placement at the T10-T11.", + "The spinal cord stimulator placement was uncomplicated.", + "The patient had initially favorable results.", + "Postoperatively, the patient complained of paresthesias in his arms.", + "An X-ray demonstrated cranial migration of the thoracic epidural paddle to the cervical spine.", + "The stimulator/new paddle was placed again at the T10-T11 level.", + "The leads were now secured to the caudal lamina utilizing a cranial plating system.", + "The patient did well without further sequelae." + ] + }, + { + "id": "multiclinsum_test_3028_en.txt", + "fulltext": "A 48-year-old man was admitted to the emergency department 2 hours after falling from a height of 15 m, On admission, physical examination revealed a body temperature of 36.2°C, heart rate of 150 beats per minute, weak radial pulse, respiratory rate of 35 breaths per minute, blood pressure of 70/35 mm Hg, oxygen saturation of 89%, restlessness, shortness of breath, multiple skin abrasions across the body, and significant neck pain. The left chest wall was swollen, with subcutaneous emphysema and absent breath sounds on the left lung. The abdominal muscles were tense with abdominal tenderness and rebound pain. The left hip was tender with deformity and shortening of the left lower limb. Laboratory tests showed: arterial blood gases: pH 7.21, PO2 53 mm Hg, PCO2 28 mm Hg, lactate 3.6 mol/L; complete blood count: white blood cells 22.77 × 109/L, hemoglobin 114 g/L, hematocrit 33.6%, platelet count 233 × 109/L; coagulation profile: prothrombin time 17.8 seconds, international normalized ratio 1.57, activated partial thromboplastin time 42.2 seconds; liver and kidney functions were normal. The timeline of interventions summarizing key events from the initial presentation to the patient’s recovery is shown.\n\nThe patient exhibited symptoms of shock, and given the clinical signs, traumatic acute left-sided tension pneumothorax was highly suspected. Immediate closed chest drainage was performed on the left side, which only drained a small amount of dark red fluid and air, suggesting other severe injuries. The patient received fluid resuscitation, norepinephrine infusion (3–6 mg/hour) to maintain blood pressure, and noninvasive ventilator support. His heart rate stabilized between 140 and 160 beats per minute, blood pressure between 90-100/50-67 mm Hg, and oxygen saturation between 95% and 98%. Bedside point-of-care ultrasound (POCUS) revealed substantial echogenic abnormalities within the left thoracic cavity and rightward displacement of the heart, suggesting left-sided tension viscerothorax. To confirm the diagnosis, an urgent chest and abdominal computed tomography (CT) scan was performed.\n\nUpon returning to the resuscitation room after the CT scan, the patient suddenly lost consciousness, was unresponsive when called, and his carotid pulse disappeared, indicating cardiac arrest. Immediate cardiopulmonary resuscitation and advanced life support were initiated, and the patient regained spontaneous circulation after 5 minutes. He was then urgently taken to the operating room. Emergency surgery repaired the lung laceration, diaphragmatic rupture, reduced left rib fractures, and repositioned the stomach, omentum, spleen, and part of the left liver lobe into the abdominal cavity, and a left-sided chest drain was placed. Postoperative chest CT scans were performed. The patient was discharged on the 18th day of hospitalization, showing satisfactory recovery.\n\nThe patient was closely monitored for 2 years postdischarge. The first follow-up occurred 6 months after discharge, during which a chest CT scan was performed. At this time, the patient reported no symptoms and was able to engage in physical activities at pre-injury levels. The second follow-up took place 2 years postdischarge. This consistent monitoring confirms that the patient has had a favorable long-term outcome, with no complications related to the initial injury. The patient remained asymptomatic, and a chest X-ray conducted at this follow-up also showed normal findings.", + "fulltext_subclaims": [ + "The patient was a 48-year-old man.", + "He was admitted to the emergency department 2 hours after falling from a height of 15 m.", + "On admission, physical examination revealed a body temperature of 36.2°C.", + "On admission, physical examination revealed a heart rate of 150 beats per minute.", + "On admission, physical examination revealed weak radial pulse.", + "On admission, physical examination revealed a blood pressure of 70/35 mm Hg.", + "On admission, physical examination revealed oxygen saturation of 89%.", + "On admission, physical examination revealed multiple skin abrasions across the body.", + "On admission, physical examination revealed significant neck pain.", + "The left chest wall was swollen.", + "The left chest wall had subcutaneous emphysema.", + "The left chest wall had absent breath sounds on the left lung.", + "The abdominal muscles were tense.", + "The abdominal muscles had abdominal tenderness.", + "The abdominal muscles had rebound pain.", + "The left hip was tender.", + "The left hip had deformity.", + "The left lower limb had shortening.", + "Arterial blood gases showed pH 7.21.", + "Arterial blood gases showed PO2 53 mm Hg.", + "Arterial blood gases showed PCO2 28 mm Hg.", + "Arterial blood gases showed lactate 3.6 mol/L.", + "Complete blood count showed white blood cells 22.77 × 10^9/L.", + "Complete blood count showed hemoglobin 114 g/L.", + "Complete blood count showed hematocrit 33.6%.", + "Complete blood count showed platelet count 233 × 10^9/L.", + "Coagulation profile showed prothrombin time 17.8 seconds.", + "Coagulation profile showed international normalized ratio 1.57.", + "Coagulation profile showed activated partial thromboplastin time 42.2 seconds.", + "Liver and kidney functions were normal.", + "The patient exhibited symptoms of shock.", + "Traumatic acute left-sided tension pneumothorax was highly suspected.", + "Immediate closed chest drainage was performed on the left side.", + "The closed chest drainage only drained a small amount of dark red fluid and air.", + "The patient received fluid resuscitation.", + "The patient received norepinephrine infusion (3–6 mg/hour) to maintain blood pressure.", + "The patient received noninvasive ventilator support.", + "Bedside point-of-care ultrasound revealed substantial echogenic abnormalities within the left thoracic cavity.", + "Bedside point-of-care ultrasound revealed rightward displacement of the heart.", + "An urgent chest and abdominal computed tomography scan was performed.", + "Upon returning to the resuscitation room after the CT scan, the patient suddenly lost consciousness.", + "The patient was unresponsive when called.", + "The patient's carotid pulse disappeared, indicating cardiac arrest.", + "Immediate cardiopulmonary resuscitation and advanced life support were initiated.", + "The patient regained spontaneous circulation after 5 minutes.", + "Emergency surgery repaired the lung laceration.", + "Emergency surgery repaired the diaphragmatic rupture.", + "Emergency surgery reduced left rib fractures.", + "Emergency surgery repositioned the stomach, omentum, spleen, and part of the left liver lobe into the abdominal cavity.", + "A left-sided chest drain was placed.", + "Postoperative chest CT scans were performed.", + "The patient was discharged on the 18th day of hospitalization.", + "The patient showed satisfactory recovery.", + "The patient was closely monitored for 2 years postdischarge.", + "The first follow-up occurred 6 months after discharge.", + "A chest CT scan was performed at the first follow-up.", + "At the first follow-up, the patient reported no symptoms.", + "At the first follow-up, the patient was able to engage in physical activities at pre-injury levels.", + "The second follow-up took place 2 years postdischarge.", + "The patient remained asymptomatic at the second follow-up.", + "A chest X-ray conducted at the second follow-up showed normal findings." + ], + "summary": "Patient concerns: A 48-year-old male was urgently admitted to the emergency department with dyspnea following a fall from a height of 15 m.\n\nDiagnoses: The patient, presenting in shock and based on clinical signs, was initially diagnosed with a tension pneumothorax (TPT). Bedside point-of-care ultrasound (POCUS) revealed substantial parenchymal echo abnormalities in the left thoracic cavity and cardiac displacement to the right, suggesting a left-sided tension viscerothorax. Thoracic and abdominal computed tomography confirmed the diagnosis of a rare left-sided tension viscerothorax.\n\nInterventions: Due to the delayed diagnosis, the patient experienced a cardiac arrest. Following cardiopulmonary resuscitation and advanced life support, the patient regained spontaneous circulation and underwent an emergency laparotomy to reduce abdominal organs and repair a diaphragmatic hernia. Postoperatively, the patient received comprehensive medical care.\n\nOutcomes: The patient recovered well postsurgery and was discharged after an 18-day hospital stay. Follow-up over 2 years revealed no significant complications.", + "summary_subclaims": [ + "The patient is a 48-year-old male.", + "The patient was urgently admitted to the emergency department.", + "The patient had dyspnea following a fall from a height of 15 m.", + "The patient was initially diagnosed with a tension pneumothorax.", + "Bedside point-of-care ultrasound revealed substantial parenchymal echo abnormalities in the left thoracic cavity.", + "Bedside point-of-care ultrasound showed cardiac displacement to the right.", + "The ultrasound findings suggested a left-sided tension viscerothorax.", + "Thoracic and abdominal computed tomography confirmed the diagnosis of a rare left-sided tension viscerothorax.", + "The patient experienced a cardiac arrest due to the delayed diagnosis.", + "The patient underwent cardiopulmonary resuscitation.", + "The patient received advanced life support.", + "The patient regained spontaneous circulation.", + "The patient underwent an emergency laparotomy.", + "The laparotomy was performed to reduce abdominal organs.", + "The laparotomy was performed to repair a diaphragmatic hernia.", + "The patient was discharged after an 18-day hospital stay.", + "Follow-up over 2 years revealed no significant complications." + ] + }, + { + "id": "multiclinsum_test_1232_en.txt", + "fulltext": "A 57-year-old Japanese woman presented with a 1.5-year history of right hip pain when she walked long distances. She had a history of bilateral developmental dysplasia of the hip and had undergone bilateral acetabular osteotomies in childhood. There was no history of trauma, anticoagulant use, or a collagen vascular disorder. She is a housewife. She has no medical history and family history.\nA physical examination revealed a firm, immobile mass measuring 18 cm × 12 cm located on the right side of her ilium. An operation scar measuring 14 cm was found in the front of her hip joint. There was no redness of the skin or swelling of the inguinal lymph nodes. There were no neurological signs of motor or sensory disturbances in her limbs. She could walk with one axillary crutch on one arm and could stand on her right leg. The joint motions of her right hip joint were − 20° extension, 30° flexion, 20° abduction, and 10° adduction. There were no differences in the circumferences of her lower limbs. All laboratory data were within normal limits including coagulation studies: white blood cells (WBC) 7300/uL, hemoglobin 12.8, platelet 22.6 × 104/μL, C-reactive protein (CRP) 0.12 mg/dL, aspartate aminotransferase (AST) 15 U/L, alanine aminotransferase (ALT) 11 U/L, blood urea nitrogen (BUN) 11 mg/dL, creatinine 0.50 mg/dL, activated partial thromboplastin time (APTT) 27.8 seconds, and prothrombin time-international normalized ratio (PT-INR) 0.97 INR).\nA plain radiograph revealed expanded deformity of her right ilium with marginal sclerosis and calcification inside the bone . Computed tomography demonstrated a heterogeneous mass around the ilium and an area of destroyed bone . On magnetic resonance imaging of the same sites, the lesion showed predominantly isointense or high signals on T1-weighted images, and a mixture of low and high signal intensities on T2-weighted images. There was visible heterogeneous enhancement of the mass on a T1-weighted image following the intravenous injection of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA) .\nBased on these findings, our differential diagnoses were giant cell tumor of the bone, aneurysmal bone cyst, or low-grade malignant tumor such as telangiectatic osteosarcoma. Therefore, an incisional biopsy of the lesion was performed. An intraoperative examination revealed that the lesion had a thick capsule; when the capsule was incised, abundant blood was drained from inside. The intraoperative hemorrhage from the incisional biopsy was 500 ml; then, our patient needed a blood transfusion because her hemoglobin level decreased to 6.7 mg/dl from the preoperative level of 12.8 mg/dl. A histopathologic examination revealed large amounts of old clotted blood within the lesion. The capsule of the lesion was composed of dense, fibrous, connective tissue . There was no evidence of neoplasia . Therefore, CEH was suspected.\nWe discussed the treatment options of the current case because there was no previous example of a huge CEH of bone. Surgical treatment was not recommended due to inaccessibility based on our experience of the intraoperative massive hemorrhage at the previous biopsy. We selected non-operative management for the current case. A consecutive selective arterial embolization program was started and performed five times . In addition, our patient was submitted to an off-label treatment with denosumab, which is a monoclonal antibody and acts as an inhibitor of the RANK/RANKL pathway and diminishes bone turnover. Denosumab was administered using the regimen for giant cell tumors of bone and continued for 3 months. However, the lesion continued to slowly grow, and neuralgia of the femoral nerve occurred , so we suspected that it might be a malignant bone tumor and decided to perform surgical treatment. We expected that we would be unable to prevent and control the operative bleeding in curettage or volume reduction surgery in this case. Therefore, we performed an internal hemipelvectomy, including the capsule of the mass 2.5 years after the incisional biopsy.\nAt the operation, the mass was completely covered in a capsule, with no evidence of invasion of the neighboring muscle. On macroscopic examination, the lesion was encased in a thick capsule . After the lesion was excised, a hip transposition was done as a limb salvage procedure . On microscopic examination, the mass was composed of a mixture of fibrin, blood clots, and hemosiderin deposition with a fibrous layer containing degenerated muscle fibers and new capillaries. A histopathologic examination confirmed the diagnosis of CEH consistent with the diagnosis indicated by the incisional biopsy.\nExternal fixation of her pelvis and her right femur was applied for 6 weeks postoperatively. After removing the external fixation, partial weight-bearing was permitted for 4 weeks, and full weight-bearing with one crutch was allowed 14 weeks postoperatively.\nThere was no recurrence of CEH at the most recent follow-up of 1 year and 8 months postoperatively. She can ambulate with the assistance of one crutch and a heel lift of 5 cm .", + "fulltext_subclaims": [ + "The patient is a 57-year-old Japanese woman.", + "She had a 1.5-year history of right hip pain when walking long distances.", + "She had a history of bilateral developmental dysplasia of the hip.", + "She had undergone bilateral acetabular osteotomies in childhood.", + "There was no history of trauma.", + "There was no history of anticoagulant use.", + "There was no history of a collagen vascular disorder.", + "A physical examination revealed a firm, immobile mass measuring 18 cm × 12 cm located on the right side of her ilium.", + "An operation scar measuring 14 cm was found in the front of her hip joint.", + "There was no redness of the skin.", + "There was no swelling of the inguinal lymph nodes.", + "She could walk with one axillary crutch on one arm.", + "The joint motions of her right hip joint were − 20° extension, 30° flexion, 20° abduction, and 10° adduction.", + "All laboratory data were within normal limits.", + "A plain radiograph revealed expanded deformity of her right ilium with marginal sclerosis and calcification inside the bone.", + "Computed tomography demonstrated a heterogeneous mass around the ilium and an area of destroyed bone.", + "On magnetic resonance imaging, the lesion showed predominantly isointense or high signals on T1-weighted images.", + "On magnetic resonance imaging, the lesion showed a mixture of low and high signal intensities on T2-weighted images.", + "There was visible heterogeneous enhancement of the mass on a T1-weighted image following the intravenous injection of Gd-DTPA.", + "The differential diagnoses were giant cell tumor of the bone, aneurysmal bone cyst, or low-grade malignant tumor such as telangiectatic osteosarcoma.", + "An incisional biopsy of the lesion was performed.", + "The intraoperative hemorrhage from the incisional biopsy was 500 ml.", + "The patient needed a blood transfusion because her hemoglobin level decreased to 6.7 mg/dl.", + "A histopathologic examination revealed large amounts of old clotted blood within the lesion.", + "The capsule of the lesion was composed of dense, fibrous, connective tissue.", + "There was no evidence of neoplasia.", + "CEH was suspected.", + "Surgical treatment was not recommended due to inaccessibility based on the experience of intraoperative massive hemorrhage at the previous biopsy.", + "Non-operative management was selected for the current case.", + "A consecutive selective arterial embolization program was started and performed five times.", + "The patient was submitted to an off-label treatment with denosumab.", + "Denosumab was administered using the regimen for giant cell tumors of bone.", + "Denosumab was continued for 3 months.", + "The lesion continued to slowly grow.", + "Neuralgia of the femoral nerve occurred.", + "We suspected that it might be a malignant bone tumor.", + "We decided to perform surgical treatment.", + "We performed an internal hemipelvectomy, including the capsule of the mass 2.5 years after the incisional biopsy.", + "On macroscopic examination, the lesion was encased in a thick capsule.", + "A histopathologic examination confirmed the diagnosis of CEH.", + "External fixation of her pelvis and her right femur was applied for 6 weeks postoperatively.", + "Partial weight-bearing was permitted for 4 weeks after removing the external fixation.", + "Full weight-bearing with one crutch was allowed 14 weeks postoperatively.", + "There was no recurrence of CEH at the most recent follow-up of 1 year and 8 months postoperatively.", + "She can ambulate with the assistance of one crutch and a heel lift of 5 cm." + ], + "summary": "A 57-year-old Japanese woman presented with a 1.5-year history of right hip pain. She had a history of bilateral developmental dysplasia of the hip and had undergone bilateral arthroplasties in childhood. A physical examination revealed a large, firm, immobile mass at her right ilium. Based on radiographic findings, a type of slow-growing bone tumor was suspected, and an incisional biopsy was performed. A histopathologic examination revealed large amounts of old clotted blood within the lesion, and the capsule of the lesion was composed of dense, fibrous, connective tissue. There was no evidence of neoplasia, and chronic expanding hematoma was suspected. The lesion was resistant to conservative treatment, and so we performed an internal hemipelvectomy (including the capsule of the mass) and a reconstruction by hip transposition 2.5 years after the incisional biopsy. There was no recurrence of chronic expanding hematoma at the most recent follow-up of 1 year and 8 months postoperatively.", + "summary_subclaims": [ + "The patient is a 57-year-old Japanese woman.", + "She had a 1.5-year history of right hip pain.", + "She had a history of bilateral developmental dysplasia of the hip.", + "She had undergone bilateral arthroplasties in childhood.", + "A physical examination revealed a large, firm, immobile mass at her right ilium.", + "A type of slow-growing bone tumor was suspected based on radiographic findings.", + "An incisional biopsy was performed.", + "A histopathologic examination revealed large amounts of old clotted blood within the lesion.", + "The capsule of the lesion was composed of dense, fibrous, connective tissue.", + "There was no evidence of neoplasia.", + "Chronic expanding hematoma was suspected.", + "The lesion was resistant to conservative treatment.", + "An internal hemipelvectomy was performed.", + "The internal hemipelvectomy included the capsule of the mass.", + "A reconstruction by hip transposition was performed.", + "The hip transposition was performed 2.5 years after the incisional biopsy.", + "There was no recurrence of chronic expanding hematoma at the most recent follow-up.", + "The most recent follow-up was 1 year and 8 months postoperatively." + ] + }, + { + "id": "multiclinsum_test_169_en.txt", + "fulltext": "A 47-year old male patient presented to the emergency department of our center with a 4-day history of moderate abdominal pain increasing gradually in severity over the duration of illness. The pain started as generalized all over the abdomen, and then mobilized to the right iliac fossa. The pain was associated with frequented vomiting which started as greenish juice then became food particles. It was also associated with increased an abdominal girth and obstipation. Physical assessment showed a distressed patient with a respiratory rate of 22 and heart rate of 120 bpm. His Blood pressure was 90/60 and Temp 37.8° C orally. O2 Saturation was 90 at room air. Abdominal examination revealed marked abdominal distention, with localized guarding in right iliac fossa. On Digital rectal examination there was no masses or blood and no stool. On presentation, laboratory findings included elevated Creatinine (1.5 mg/dl), BUN (27.0), Na (143) and normal WBC count (5900 cell/mm3), hemoglobin (10.4 g/dl), platelets (136 × 103/μl), INR 1.7. Plain abdominal radiographs showed dilated small and large bowel loops .\nThe abdomen CT scans with contrast enhancement was advised after resuscitating the patient and stabilizing his condition, and showed dilated small and large bowel with sigmoid volvulus plus large amount of preihepatic and pelvic free fluid. Swirl sign at the mesentery of cecum suspected strangulated bowels due to transmesentric defect . Intraoperative findings: 2 × 4 cm defect in the mesentery of cecum, Gangrenous sigmoid volvulus and part of the terminal ileum entrapped through the mesenteric gate, and much free fluid . Surgical treatment started with deflating the sigmoid colon, and reducing it through the defect. We also reduced the small bowel. After that, resection of all nonviable segments was performed. End-to-end anastomosis of small bowel, colostomy on the left side, and closure of defect was done. Immediately after recovery from surgery, the patient was transferred to ICU and stayed for three days, during which he developed atelectasis and systemic inflammatory response with acute kidney injury and blood hemolysis but these rapidly reverted to normal. Following that, the patient was transferred to surgical ward in which he spent seven days with a complication of superficial wound infection and ileus. The infection was treated with IV antibiotics according to antimicrobial susceptibility testing and dressing was applied. Ileus was treated conservatively. On the tenth postoperative day, the patient was discharged with functioning stoma and excellent general condition. We are planning to restore GI continuity after 3 months.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "The patient presented with a 4-day history of moderate abdominal pain.", + "The pain started as generalized all over the abdomen.", + "The pain mobilized to the right iliac fossa.", + "The pain was associated with frequented vomiting.", + "The vomiting started as greenish juice.", + "The vomiting became food particles.", + "The pain was associated with increased abdominal girth.", + "The pain was associated with obstipation.", + "Physical assessment showed a respiratory rate of 22.", + "Physical assessment showed a heart rate of 120 bpm.", + "Blood pressure was 90/60.", + "Temperature was 37.8° C orally.", + "O2 saturation was 90 at room air.", + "Abdominal examination revealed marked abdominal distention.", + "Abdominal examination showed localized guarding in the right iliac fossa.", + "Digital rectal examination showed no masses.", + "Digital rectal examination showed no blood.", + "Digital rectal examination showed no stool.", + "Laboratory findings included elevated creatinine (1.5 mg/dl).", + "Laboratory findings included elevated BUN (27.0).", + "Laboratory findings included normal WBC count (5900 cell/mm3).", + "Plain abdominal radiographs showed dilated small and large bowel loops.", + "CT scans with contrast enhancement showed dilated small and large bowel.", + "CT scans showed sigmoid volvulus.", + "CT scans showed a large amount of preihepatic and pelvic free fluid.", + "CT scans showed a swirl sign at the mesentery of the cecum.", + "Intraoperative findings included a 2 × 4 cm defect in the mesentery of the cecum.", + "Intraoperative findings included gangrenous sigmoid volvulus.", + "Intraoperative findings included part of the terminal ileum entrapped through the mesenteric gate.", + "Surgical treatment included deflating the sigmoid colon.", + "Surgical treatment included reducing the sigmoid colon through the defect.", + "Surgical treatment included reducing the small bowel.", + "Surgical treatment included resection of all nonviable segments.", + "Surgical treatment included end-to-end anastomosis of small bowel.", + "Surgical treatment included colostomy on the left side.", + "Surgical treatment included closure of the defect.", + "The patient was transferred to ICU after surgery.", + "The patient stayed in ICU for three days.", + "The patient developed atelectasis.", + "The patient developed systemic inflammatory response.", + "The patient developed acute kidney injury.", + "The patient developed blood hemolysis.", + "The patient was transferred to the surgical ward.", + "The patient spent seven days in the surgical ward.", + "The patient had a complication of superficial wound infection.", + "The infection was treated with IV antibiotics.", + "Ileus was treated conservatively.", + "The patient was discharged on the tenth postoperative day.", + "The patient had a functioning stoma.", + "The patient had an excellent general condition at discharge.", + "We are planning to restore GI continuity after 3 months." + ], + "summary": "We report a 47- year- old male with generalized abdominal pain associated with vomiting and obstipation. The patient was in hypovolemic shock that only had a transient response to resuscitation. CT scans of the abdomen with contrast was done and showed both large and small bowel obstruction. Exploration laparotomy was done and revealed a concurrent nonviable portion of ileum and twisted sigmoid colon (volvulus) which protruded through a congenital transmesentric defect. Resection was mandatory, and repair of the defect was done.", + "summary_subclaims": [ + "The patient is a 47-year-old male.", + "The patient had generalized abdominal pain.", + "The patient had vomiting.", + "The patient had obstipation.", + "The patient was in hypovolemic shock.", + "The hypovolemic shock had a transient response to resuscitation.", + "CT scans of the abdomen with contrast showed both large and small bowel obstruction.", + "Exploration laparotomy was done.", + "A concurrent nonviable portion of ileum was found.", + "A twisted sigmoid colon (volvulus) was found.", + "The volvulus protruded through a congenital transmesentric defect.", + "Resection was mandatory.", + "Repair of the defect was done." + ] + }, + { + "id": "multiclinsum_test_947_en.txt", + "fulltext": "A 57-year-old woman presented with intermittent gross hematuria for 2 years. She did not report any other symptoms. Physical examination indicated no abnormal findings. Blood cell counts and biochemical tests were within the reference range. Urinalysis displayed hematuria. Therefore, it was suggested that she should undergo a urinary system ultrasound examination. The kidney and ureter ultrasounds indicated no abnormal findings, whereas the bladder ultrasound revealed an avascular and homogeneous isoechoic polypoid mass with a maximum diameter of 6 mm at the right lateral wall of the bladder . She has no bladder tumors history or family history. So, the bladder of the patient was examined endoscopically and a polypoid lesion (6 mm in maximum diameter) was noted with a smooth surface, located in the right lateral wall . Subsequently, a transurethral resection (TUR) was performed and the lesion was easily removed. Microscopic examination indicated that the neoplasm was well circumscribed and composed of nests of monomorphic cells with bland nuclei and eosinophilic cytoplasm, clustered around dilated vessels. Atypia, mitoses, intravascular growth and necrosis were absent . Immunohistochemical staining revealed that the neoplastic cells reacted positively to the smooth muscle actin (SMA) and vimentin, whereas they were negative to desmin . A diagnosis of benign bladder GT was made. The patient remained asymptomatic and no recurrence was observed within a 2-year follow up.", + "fulltext_subclaims": [ + "The patient is a 57-year-old woman.", + "She had intermittent gross hematuria for 2 years.", + "She did not report any other symptoms.", + "Physical examination indicated no abnormal findings.", + "Blood cell counts and biochemical tests were within the reference range.", + "Urinalysis displayed hematuria.", + "It was suggested that she should undergo a urinary system ultrasound examination.", + "The kidney and ureter ultrasounds indicated no abnormal findings.", + "The bladder ultrasound revealed an avascular and homogeneous isoechoic polypoid mass with a maximum diameter of 6 mm at the right lateral wall of the bladder.", + "She has no bladder tumors history.", + "She has no family history of bladder tumors.", + "The patient's bladder was examined endoscopically.", + "A polypoid lesion (6 mm in maximum diameter) was noted with a smooth surface, located in the right lateral wall.", + "A transurethral resection (TUR) was performed.", + "The lesion was easily removed.", + "Microscopic examination indicated that the neoplasm was well circumscribed.", + "The neoplasm was composed of nests of monomorphic cells with bland nuclei and eosinophilic cytoplasm.", + "The cells were clustered around dilated vessels.", + "Atypia was absent.", + "Mitoses were absent.", + "Intravascular growth was absent.", + "Necrosis was absent.", + "Immunohistochemical staining revealed that the neoplastic cells reacted positively to smooth muscle actin (SMA).", + "Immunohistochemical staining revealed that the neoplastic cells reacted positively to vimentin.", + "Immunohistochemical staining revealed that the neoplastic cells were negative to desmin.", + "A diagnosis of benign bladder GT was made.", + "The patient remained asymptomatic.", + "No recurrence was observed within a 2-year follow up." + ], + "summary": "A 57-year-old woman presented with intermittent gross hematuria for 2 years. Urinalysis displayed hematuria. The bladder ultrasound showed an avascular and homogeneous isoechoic polypoid mass with a maximum diameter of 6 mm at the right lateral wall of bladder. The bladder endoscopic examination showed a polypoid lesion, with a smooth surface, located in the right lateral wall. Then, a transurethral resection was performed, its histopathological features indicated a benign GT.", + "summary_subclaims": [ + "The patient is a 57-year-old woman.", + "She had intermittent gross hematuria for 2 years.", + "Urinalysis displayed hematuria.", + "The bladder ultrasound showed an avascular and homogeneous isoechoic polypoid mass.", + "The mass had a maximum diameter of 6 mm at the right lateral wall of the bladder.", + "The bladder endoscopic examination showed a polypoid lesion.", + "The lesion had a smooth surface.", + "The lesion was located in the right lateral wall.", + "A transurethral resection was performed.", + "The histopathological features indicated a benign GT." + ] + }, + { + "id": "multiclinsum_test_1707_en.txt", + "fulltext": "A 30-year-old, ill-appearing South Asian male patient presented to the emergency department with new-onset fever, chest discomfort, macular exanthema, abdominal pain, coughing, mild dyspnoea, and tachypnoea for a couple of days. The patient’s medical history was unremarkable except for a recent infection with SARS-CoV-2 about a month prior to the current presentation. There was no history of smoking or a family history of cardiovascular disease and the patient had a mildly increased body mass index of 29. The course of the COVID-19 disease was mild with only minor symptoms of respiratory infection, most notably coughing, did not require further medical attention, and the patient recovered completely without any residual symptoms. The patient had not been vaccinated prior to COVID-19 infection or since then. Upon admission to the emergency department, the patient tested negative for SARS-CoV-2 nucleic acids in consecutive nasopharyngeal swabs. Antibody-testing for SARS-CoV-2 was positive with 164 U/mL, confirming past COVID-19 infection.\nOn examination, a widespread, itching, non-scaling macular exanthema was evident, which originated at the lower legs and had since spread to the trunk. Additionally, mild abdominal tenderness was localized in the epigastric area and pulmonary auscultation revealed bilateral fine rales in the lung bases. Upon cardiac auscultation, no murmurs or pathological heart sounds were evident and peripheral volume status appeared euvolaemic. The further physical exam was unremarkable and vital signs were initially stable. Laboratory work-up showed significant inflammation [white blood cells 11.7 G/L and c-reactive protein (CRP) 155 mg/L] and a mild increase of markers of myocyte necrosis and myocardial stretch [high-sensitive cardiac troponin I (hs-cTnI) 84 ng/L and N-terminal pro-B-type natriuretic peptide (NT-proBNP) 476 ng/L] . Upon chest X-ray, bilateral diffuse reticular abnormalities were described in both lungs . The patient was started on i.v. broad-spectrum, empiric antibiotics after blood cultures were drawn (ceftriaxone 2 g i.v. and azithromycin 500 mg p.o.) and was subsequently admitted to the department of pulmonary medicine. High-resolution chest computed tomography (CT), which was issued to further characterize the X-ray findings, showed mild bilateral, multilobular interstitial abnormalities, and ground-glass opacities most notably in the basal sections of the lung . These findings were compatible with a history of SARS-CoV-2 infection and there were no signs of acute bacterial pneumonia or severe respiratory disease.\nUpon laboratory follow-up, a significant increase of both hs-cTnI and NT-proBNP was noted. The electrocardiogram was unremarkable except for sinus tachycardia with a heart rate of 120 beats per minute and peripheral low voltage. Transthoracic echocardiography showed mildly reduced left ventricular ejection fraction of 49% without evidence of regional wall motion abnormalities (, ). Since the patient continued to suffer from chest discomfort referral for acute coronary angiography was issued, which excluded coronary artery disease. Ventriculography confirmed mildly reduced left ventricular systolic function with an ejection fraction of 43%. . The patient was then transferred to our cardiological ward for haemodynamic monitoring and further management. To confirm the current tentative diagnosis of acute myocarditis, cardiac magnetic resonance imaging (MRI) was arranged. Pulmonary embolism may also be considered as a potential differential diagnosis in this setting. However, since the pre-test probability for pulmonary embolism was low (Wells Score of 1.5), echocardiography showed normal right ventricular function nor any other signs of pulmonary embolism and a different diagnosis was considered more likely, a second CT scan was omitted to reduce radiation exposure in this young patient.\nDuring the next couple of days, despite continuous antibiotic treatment, symptoms did not improve and clinical findings further deteriorated: heart rate further rose and blood pressure dropped to 90/60 mmHg. In addition to the aforementioned symptoms, we found bilateral redness of the eyes, consistent with conjunctivitis and a generalized arthralgia. Autoimmune diagnostics returned negative and we did not find any signs of acute human parvovirus B-19 infection, mononucleosis, streptococcal infection, influenza, or rubella upon diagnostic work-up, which have to be considered as potential differential diagnoses in this case. The complex, multi-organ symptom constellation with a failure of clinical improvement despite broad-spectrum antibiotics facilitated the diagnosis of MIS-A following recent mildly symptomatic SARS-CoV-2 infection. According to current literature, the patient was started on a 100 mg daily dose of aspirin and an intravenous hydrocortisone drip with 200 mg/day after an initial bolus of 100 mg. The patient’s symptoms and haemodynamic parameters improved drastically following the start of steroid treatment. We also observed a prompt and steady decrease of inflammatory markers and the last fever spike of 39°C was documented on the day of steroid initiation. Cardiac MRI finally confirmed acute myocarditis with findings of myocardial oedema, late gadolinium enhancement and small pericardial effusion—at this point, in time the patient was already feeling better and only suffered from intermittent and mild chest pain .\nAfter 6 days of intravenous corticosteroid treatment—stopped without tapering—the patient was discharged from hospital care without significant residual symptoms. The necessity of strict, physical activity restriction for 3–6 months was discussed with the patient. There were no adverse or unanticipated events secondary to corticosteroid treatment. Upon 2-week follow-up, the patient was feeling well and there was no symptom recurrence. Echocardiography at 6-week follow-up revealed a normalization of systolic left ventricular function alongside a normalization of laboratory markers of myocardial injury. Antithrombotic treatment with aspirin was also stopped at this point.", + "fulltext_subclaims": [ + "The patient was a 30-year-old, ill-appearing South Asian male.", + "The patient presented with new-onset fever, chest discomfort, macular exanthema, abdominal pain, coughing, mild dyspnoea, and tachypnoea for a couple of days.", + "The patient had a recent infection with SARS-CoV-2 about a month prior to the current presentation.", + "The course of the COVID-19 disease was mild with only minor symptoms of respiratory infection.", + "The patient had not been vaccinated prior to or since the SARS-CoV-2 infection.", + "Upon admission, the patient tested negative for SARS-CoV-2 nucleic acids in consecutive nasopharyngeal swabs.", + "Antibody-testing for SARS-CoV-2 was positive with 164 U/mL, confirming past infection.", + "A widespread, itching, non-scaling macular exanthema was evident, originating at the lower legs and spreading to the trunk.", + "Mild abdominal tenderness was localized in the epigastric area.", + "Pulmonary auscultation revealed bilateral fine rales in the lung bases.", + "Cardiac auscultation showed no murmurs or pathological heart sounds.", + "Laboratory work-up showed white blood cells of 11.7 G/L and CRP of 155 mg/L.", + "Chest X-ray showed bilateral diffuse reticular abnormalities in both lungs.", + "The patient was started on i.v. broad-spectrum antibiotics after blood cultures were drawn.", + "High-resolution chest CT showed mild bilateral, multilobular interstitial abnormalities and ground-glass opacities in the basal sections of the lung.", + "These findings were compatible with a history of SARS-CoV-2 infection.", + "There were no signs of acute bacterial pneumonia or severe respiratory disease.", + "A significant increase of both hs-cTnI and NT-proBNP was noted.", + "The electrocardiogram showed sinus tachycardia with a heart rate of 120 beats per minute and peripheral low voltage.", + "Transthoracic echocardiography showed a mildly reduced left ventricular ejection fraction of 49%.", + "Acute coronary angiography excluded coronary artery disease.", + "Ventriculography confirmed mildly reduced left ventricular systolic function with an ejection fraction of 43%.", + "The patient was transferred to the cardiological ward.", + "Cardiac MRI was arranged to confirm the diagnosis of acute myocarditis.", + "Pulmonary embolism may also be considered as a potential differential diagnosis.", + "The pre-test probability for pulmonary embolism was low (Wells Score of 1.5).", + "Echocardiography showed normal right ventricular function.", + "A second CT scan was omitted to reduce radiation exposure.", + "Symptoms did not improve despite continuous antibiotic treatment.", + "Heart rate further rose and blood pressure dropped to 90/60 mmHg.", + "Bilateral redness of the eyes, consistent with conjunctivitis, was found.", + "Autoimmune diagnostics returned negative.", + "There were no signs of acute human parvovirus B-19 infection, mononucleosis, streptococcal infection, influenza, or rubella.", + "The diagnosis of MIS-A following recent mildly symptomatic SARS-CoV-2 infection was made.", + "The patient was started on a 100 mg daily dose of aspirin.", + "The patient was started on an intravenous hydrocortisone drip with 200 mg/day after an initial bolus of 100 mg.", + "The patient’s symptoms and haemodynamic parameters improved drastically following the start of steroid treatment.", + "A prompt and steady decrease of inflammatory markers was observed.", + "The last fever spike of 39°C was documented on the day of steroid initiation.", + "Cardiac MRI confirmed acute myocarditis with findings of myocardial oedema, late gadolinium enhancement, and small pericardial effusion.", + "The patient was discharged after 6 days of intravenous corticosteroid treatment.", + "The necessity of strict, physical activity restriction for 3–6 months was discussed.", + "There were no adverse or unanticipated events secondary to corticosteroid treatment.", + "At 2-week follow-up, the patient was feeling well with no symptom recurrence.", + "Echocardiography at 6-week follow-up revealed normalization of systolic left ventricular function.", + "Antithrombotic treatment with aspirin was stopped at 6-week follow-up." + ], + "summary": "A 30-year-old male patient presented to the emergency department with new-onset of fever, chest discomfort, macular exanthema, abdominal pain, mild dyspnoea, and coughing. The patient reported a mildly symptomatic recent coronavirus disease-19 (COVID-19). Significantly increased markers of inflammation and a modest increase of cardiac troponin were found upon laboratory work-up at admission. Despite broad-spectrum antibiotics, the patient's clinical status deteriorated continuously. Cardiac work-up, including echocardiography, coronary angiography, and cardiac magnetic resonance imaging, was done and signs of acute myocarditis with mildly reduced left ventricular systolic function were found. The complex multi-organ symptom constellation facilitated the diagnosis of MIS-A following COVID-19 infection. Besides aspirin, intravenous, continuous hydrocortisone treatment was initiated, resulting in a prompt improvement of symptoms and clinical findings.", + "summary_subclaims": [ + "A 30-year-old male patient presented to the emergency department with new-onset of fever, chest discomfort, macular exanthema, abdominal pain, mild dyspnoea, and coughing.", + "The patient reported a mildly symptomatic recent coronavirus disease-19 (COVID-19).", + "Significantly increased markers of inflammation and a modest increase of cardiac troponin were found upon laboratory work-up at admission.", + "Despite broad-spectrum antibiotics, the patient's clinical status deteriorated continuously.", + "Cardiac work-up, including echocardiography, coronary angiography, and cardiac magnetic resonance imaging, was done.", + "Signs of acute myocarditis with mildly reduced left ventricular systolic function were found.", + "The complex multi-organ symptom constellation facilitated the diagnosis of MIS-A following COVID-19 infection.", + "Besides aspirin, intravenous, continuous hydrocortisone treatment was initiated.", + "The treatment resulted in a prompt improvement of symptoms and clinical findings." + ] + }, + { + "id": "multiclinsum_test_1415_en.txt", + "fulltext": "A 54-year-old Moroccan man with a history of psoriasis in remission presented with a 3-month history of erythematous nonpruritic lesions of the face with hypersensitivity to heat. A clinical examination revealed erythematous, telangiectatic, confluent papules of the lateral side around the eyes without any scales, crusts, or pustules. In the differential diagnosis, we included GR, sarcoidosis, lupus vulgaris, and lupus erythematosus tumidus. Dermoscopy revealed linear vessels characteristically arranged in a polygonal network, creamy and whitish linear areas, and white grayish plugs surrounded by an erythematous halo filling the follicular openings .\nHistological examination of a punch biopsy specimen of the lesion showed granulomatous dermatitis with the presence of Demodex folliculorum on the biopsied tissue. These clinical, dermoscopic, and histological findings were consistent with the diagnosis of GR , and the patient was treated with topical metronidazole for a total of 10 weeks, which led to a significant improvement.", + "fulltext_subclaims": [ + "The patient is a 54-year-old Moroccan man.", + "He has a history of psoriasis in remission.", + "He had a 3-month history of erythematous nonpruritic lesions of the face with hypersensitivity to heat.", + "A clinical examination revealed erythematous, telangiectatic, confluent papules of the lateral side around the eyes.", + "There were no scales, crusts, or pustules.", + "The differential diagnosis included granulomatous rosacea, sarcoidosis, lupus vulgaris, and lupus erythematosus tumidus.", + "Dermoscopy revealed linear vessels arranged in a polygonal network.", + "Dermoscopy showed creamy and whitish linear areas.", + "Dermoscopy showed white grayish plugs surrounded by an erythematous halo filling the follicular openings.", + "Histological examination showed granulomatous dermatitis.", + "Demodex folliculorum was present on the biopsied tissue.", + "The findings were consistent with the diagnosis of granulomatous rosacea.", + "The patient was treated with topical metronidazole for a total of 10 weeks.", + "The treatment led to a significant improvement." + ], + "summary": "We report a case of a 54-year-old Moroccan man with a 3-month history of erythematous, nonpruritic papules on the lateral side around the eyes. Dermoscopy and histology confirmed the diagnosis of granulomatous rosacea.", + "summary_subclaims": [ + "The patient is a 54-year-old Moroccan man.", + "The patient had a 3-month history of erythematous, nonpruritic papules.", + "The lesions were located on the lateral side around the eyes.", + "Dermoscopy and histology confirmed the diagnosis.", + "The diagnosis was granulomatous rosacea." + ] + }, + { + "id": "multiclinsum_test_1519_en.txt", + "fulltext": "A 64-year-old woman with increased lethargy, generalized weakness, and shortness of breath on exertion was found to have pancytopenia on a routine blood count; hemoglobin 80 g/L, white blood cells 3.2 × 109/L, platelets 98 × 109/L. After bone marrow examination a diagnosis of refractory anemia with excess blasts (RAEB) was made. The symptoms were attributed to anemia and she received 5 units of packed red cells.\nApproximately 2 months later, she developed a 4-day course of intermittent chills and sweating but was afebrile when she came to the local emergency department. The CBC at admission demonstrated 6.9 × 109/L white blood cells with left shift and 0.21 × 109/L blasts, 76 g/L hemoglobin and 65 × 109/L platelets. During her hospital stay the white blood cells increased to 16.9 × 109/L with increasing left shift; anemia and thrombocytopenia persisted. There was central bronchial wall thickening and interstitial prominence in the chest radiograph suggestive of an early viral infectious process. The cardiomediastinal silhouette was within normal limits . The electrocardiogram (ECG) showed normal sinus rhythm. The patient was started on oral levofloxacin.\nFour days later, the patient became febrile (38.8 degrees) and developed increasing shortness of breath and retrosternal chest pain that radiated to both arms. There were bilateral crepitations and decreased breath sounds. Repeat chest radiograph demonstrated bilateral pleural effusions, basal consolidation of the left lower lobe and left ventricular enlargement. There was no evidence of cardiac failure . Right bundle branch block (RBBB) with sinus tachycardia was identified on ECG. An echocardiographic study identified a moderate pericardial effusion with no cardiac tamponade; the left ventricular ejection fraction was 66% and there were no regional wall motion abnormalities. The next day, a repeat echocardiographic study identified a 33% ejection fraction with left ventricular global hypokinesia and a moderate sized pericardial effusion without tamponade. The patient was treated for pneumonia, hypotension, acute renal failure, and anemia but developed heart block and cardiorespiratory compromise. Her condition deteriorated rapidly and she died five days post-admission.\nPeripheral blood and bone marrow, ante-mortem : In the peripheral blood there was dysplasia in the leukocytes (pseudo Pelger-Huet cells and hypogranular neutrophils), platelets (hypogranular platelets and large platelets) and red cells (macrocytic red cells and dimorphic red cells) was associated with a left shift and circulating blasts. The bone marrow was hypercellular with trilineage dysplasia (pseudo Pelger-Huet cells, erythroid precursors with nuclear bridging, irregular nuclear contours, irregular hemoglobinization of the cytoplasm and mononuclear and multinucleated megakaryocytes). There was abnormal localization of immature precursors (ALIP) in the core biopsy. The bone marrow aspirate differential count showed increased blasts (18.2%) while the erythroid precursors were less than 50% of the nucleated cells.\nPost-mortem examination was limited to heart and lungs at the request of the family. The heart lay free in the pericardial sac, surrounded by 300 mL of straw-colored pericardial effusion. There was fibrinous pericarditis. The free wall of the left ventricle and the interventricular septum had soft and hemorrhagic areas scattered throughout, with no definite transmural focus. The major coronary arteries (right coronary, left anterior descending, and left circumflex arteries) were involved to only a minor degree by old eccentric atherosclerotic plaques (maximum stenosis of 25 to 30%) with no evidence of an acute event (thromboembolus, hemorrhage, rupture). There was bilateral pulmonary edema and left lower lobe congestion and consolidation.\nMicroscopic examination of the heart revealed a diffuse interstitial infiltrate of immature dysplastic hemopoietic cells involving the myocardium, endocardium and the pericardium. Cells of myeloid, erythroid and megakaryocytic lineages were present. These infiltrates were associated with single fibre myocyte necrosis as well as larger foci of necrosis. A majority of these cells were immunopositive for myeloperoxidase consisted with myeloid lineage.\nPancytopenia associated with peripheral blood features including dysplastic changes in the granulocytes, <1% blasts and < 1 × 109/L monocytes coupled with multilineage dysplasia and 18.2% blasts in the bone marrow was in keeping with the diagnosis of refractory anemia with excess blasts-2 (RAEB-2) . Clinical presentation and clinical course of RAEB is typically related to the symptoms of decreased counts of one or more cell lineages and blast count [,]. The symptoms of lethargy, shortness of breath, and generalized weakness in this patient may be attributed to both anemia and cardiac infiltration by malignant cells, although the former is much more common clinically . Her cardiac symptoms were not due to drugs sometimes used in patients with myelodysplasia, since the patient had not received cytotoxic, immunomodulatory, putative differentiating agent, or hemopoietic growth factor therapy [-].\nAlthough cardiac involvement in leukemic extramedullary spread is relatively common (ranging from 37–44%) [-], clinical signs are found in less than 1% of cases [-] and leukemic cardiac involvement antemortem is usually not suspected . The most likely reason for this is the subclinical nature of the symptoms and signs in cardiac leukemic infiltration . This is in keeping with the observation that gross infiltrative disease at the time of initial diagnosis in patients with acute leukemia is rare [,,]. In the patient reported here extramedullary (cardiac) infiltration by dysplastic hemopoietic precursors by itself is not a reason to upgrade the diagnosis to acute leukemia. Extramedullary infiltration at other sites has been reported in patients with myelodysplastic syndromes [,], more frequently in patients with chronic myelomonocytic leukemia compared to RAEB and refractory cytopenia with multilineage dysplasia [,]. Although it may herald transformation to acute leukemia , this transformation may not be observed for some time [,] and sometimes not at all during follow-up [,]. Granulocyte-macrophage colony stimulating factor overproduction may lead to autonomous colony formation in the bone marrow of patients with myelodysplastic syndrome ; this may partially explain proliferation of malignant hemopoietic cells in the heart infiltrated by malignant cells.\nAlthough cardiac infiltration is usually associated with high WBC count (mostly due to blasts) and advanced disease , the presence of a high circulating white blood cell count is not a necessity for developing cardiac infiltration as infiltration has been shown to be present in aleukemic leukemia as well as in patients with very low white cell counts . The development of cardiac infiltration in our patient with myelodysplasia and pancytopenia would be consistent with this observation keeping with this pheneomenon; the rising white late in the course of the disease was was predominantly due to neutrophilia and left shift and not due to a large blast population.\nThe effects of hemopoietic cell infiltrate in the heart are varied. Leukemic deposits may form mass lesions or thrombi . Pericardial involvement may lead to pericardial effusion contributing to restrictive myocardial dysfunction [,]. Reports of heart block in extramedullary cardiac leukemic involvement are few [,,]. Heart block has been observed in patients with both very high and very low peripheral blood white cell counts and may be reversible after local radiotherapy to the heart despite persistence of leukemic infiltration . However, infiltration of the conduction system is a potentially serious complication that may be fatal . Leukemic infiltration is a rare cause of restrictive cardiomyopathy . An antemortem study of 18 patients with acute leukemia (6 ALL, 12 AML) demonstrated no significant difference from controls in LV systolic function parameters including LV ejection fraction, similar to what was observed in our patient at initial echocardiography . However, LV diastolic dysfunction has been observed in 38 percent of leukemic patients, independent of age and heart rate. It is likely that cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks and myocardial necrosis. Myocardial necrosis was most likely due to a combination of, a) ischemic damage secondary to anemia and prolonged hypotension and b) extensive leukemic infiltration. Markedly rapid decrease in ejection fraction from 66% to 33% also suggests the role of ischemia, since leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period.\nUsual causes of death in patients with myelodysplasia are related to bone marrow failure and transformation to acute leukemia [,,], however, in this patient, death was attributed to cardiac failure. It is likely that the rising white blood cell count during second admission, although predominantly due to neutrophilia and left shift, was associated with early transformation- in view of increased peripheral blood blast percentage – the limited autopsy did not permit evaluation of the bone marrow.\nCardiac involvement in by malignant hemopoietic cells is of more than just academic interest, since cardiac function has been shown to improve following therapy directed against malignant infiltrate [,]. Incorrect diagnosis during life and the fatal outcome highlight the clinical importance of considering myocardial infiltration in patients with myelodysplasia and cardiac symptoms.", + "fulltext_subclaims": [ + "The patient was a 64-year-old woman.", + "She had increased lethargy, generalized weakness, and shortness of breath on exertion.", + "She was found to have pancytopenia on a routine blood count.", + "Her hemoglobin was 80 g/L.", + "Her white blood cells were 3.2 × 109/L.", + "Her platelets were 98 × 109/L.", + "A diagnosis of refractory anemia with excess blasts (RAEB) was made after bone marrow examination.", + "The symptoms were attributed to anemia.", + "She received 5 units of packed red cells.", + "Approximately 2 months later, she developed a 4-day course of intermittent chills and sweating.", + "She was afebrile when she came to the local emergency department.", + "The CBC at admission demonstrated 6.9 × 109/L white blood cells with left shift.", + "The CBC at admission showed 0.21 × 109/L blasts.", + "The CBC at admission showed 76 g/L hemoglobin.", + "The CBC at admission showed 65 × 109/L platelets.", + "During her hospital stay, the white blood cells increased to 16.9 × 109/L with increasing left shift.", + "Anemia and thrombocytopenia persisted.", + "The chest radiograph showed central bronchial wall thickening and interstitial prominence.", + "The chest radiograph was suggestive of an early viral infectious process.", + "The cardiomediastinal silhouette was within normal limits.", + "The electrocardiogram showed normal sinus rhythm.", + "The patient was started on oral levofloxacin.", + "Four days later, the patient became febrile (38.8 degrees).", + "She developed increasing shortness of breath and retrosternal chest pain that radiated to both arms.", + "There were bilateral crepitations and decreased breath sounds.", + "Repeat chest radiograph demonstrated bilateral pleural effusions.", + "Repeat chest radiograph showed basal consolidation of the left lower lobe.", + "Repeat chest radiograph showed left ventricular enlargement.", + "There was no evidence of cardiac failure.", + "Right bundle branch block (RBBB) with sinus tachycardia was identified on ECG.", + "An echocardiographic study identified a moderate pericardial effusion with no cardiac tamponade.", + "The left ventricular ejection fraction was 66%.", + "There were no regional wall motion abnormalities.", + "A repeat echocardiographic study identified a 33% ejection fraction.", + "The repeat echocardiographic study showed left ventricular global hypokinesia.", + "The repeat echocardiographic study showed a moderate sized pericardial effusion without tamponade.", + "The patient was treated for pneumonia, hypotension, acute renal failure, and anemia.", + "She developed heart block and cardiorespiratory compromise.", + "Her condition deteriorated rapidly.", + "She died five days post-admission.", + "In the peripheral blood, there was dysplasia in the leukocytes.", + "In the peripheral blood, there was dysplasia in the platelets.", + "In the peripheral blood, there was dysplasia in the red cells.", + "The peripheral blood showed a left shift and circulating blasts.", + "The bone marrow was hypercellular with trilineage dysplasia.", + "There was abnormal localization of immature precursors (ALIP) in the core biopsy.", + "The bone marrow aspirate differential count showed increased blasts (18.2%).", + "The erythroid precursors were less than 50% of the nucleated cells.", + "Pancytopenia associated with peripheral blood features including dysplastic changes in the granulocytes, <1% blasts and < 1 × 109/L monocytes coupled with multilineage dysplasia and 18.2% blasts in the bone marrow was in keeping with the diagnosis of refractory anemia with excess blasts-2 (RAEB-2).", + "The post-mortem examination was limited to heart and lungs.", + "The heart was surrounded by 300 mL of straw-colored pericardial effusion.", + "There was fibrinous pericarditis.", + "The free wall of the left ventricle and the interventricular septum had soft and hemorrhagic areas.", + "The major coronary arteries were involved to only a minor degree by old eccentric atherosclerotic plaques.", + "There was bilateral pulmonary edema.", + "There was left lower lobe congestion and consolidation.", + "Microscopic examination of the heart revealed a diffuse interstitial infiltrate of immature dysplastic hemopoietic cells.", + "Cells of myeloid, erythroid and megakaryocytic lineages were present.", + "The infiltrates were associated with single fibre myocyte necrosis.", + "The infiltrates were associated with larger foci of necrosis.", + "A majority of these cells were immunopositive for myeloperoxidase.", + "The patient's symptoms may be attributed to both anemia and cardiac infiltration by malignant cells.", + "Her cardiac symptoms were not due to drugs used in patients with myelodysplasia.", + "Cardiac involvement in leukemic extramedullary spread is relatively common.", + "Clinical signs of cardiac involvement are found in less than 1% of cases.", + "Leukemic cardiac involvement antemortem is usually not suspected.", + "The most likely reason for this is the subclinical nature of the symptoms and signs.", + "Extramedullary infiltration at other sites has been reported in patients with myelodysplastic syndromes.", + "Extramedullary infiltration is more frequent in patients with chronic myelomonocytic leukemia.", + "Extramedullary infiltration may herald transformation to acute leukemia.", + "The rising white blood cell count was predominantly due to neutrophilia and left shift.", + "The development of cardiac infiltration in our patient with myelodysplasia and pancytopenia is consistent with this observation.", + "The effects of hemopoietic cell infiltrate in the heart are varied.", + "Leukemic deposits may form mass lesions or thrombi.", + "Pericardial involvement may lead to pericardial effusion.", + "Pericardial effusion may contribute to restrictive myocardial dysfunction.", + "Reports of heart block in extramedullary cardiac leukemic involvement are few.", + "Heart block may be reversible after local radiotherapy to the heart.", + "Infiltration of the conduction system is a potentially serious complication.", + "Leukemic infiltration is a rare cause of restrictive cardiomyopathy.", + "An antemortem study of 18 patients with acute leukemia demonstrated no significant difference from controls in LV systolic function parameters.", + "LV diastolic dysfunction has been observed in 38 percent of leukemic patients.", + "Cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy, anemia, cardiac dilatation, conduction blocks, and myocardial necrosis.", + "Myocardial necrosis was most likely due to a combination of ischemic damage and leukemic infiltration.", + "The markedly rapid decrease in ejection fraction suggests the role of ischemia.", + "Usual causes of death in patients with myelodysplasia are related to bone marrow failure and transformation to acute leukemia.", + "In this patient, death was attributed to cardiac failure.", + "The rising white blood cell count during second admission was associated with early transformation.", + "The limited autopsy did not permit evaluation of the bone marrow.", + "Cardiac involvement by malignant hemopoietic cells is of more than just academic interest.", + "Cardiac function has been shown to improve following therapy directed against malignant infiltrate.", + "Incorrect diagnosis during life and the fatal outcome highlight the clinical importance of considering myocardial infiltration in patients with myelodysplasia and cardiac symptoms." + ], + "summary": "Herein we report the first case of neoplastic infiltration of the heart with associated myocardial necrosis in a patient with myelodysplasia. It was associated with unicellular and multifocal geographic areas of necrosis in the left ventricle and the interventricular septum. It is likely that cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks and myocardial necrosis. Myocardial necrosis was most likely due to a combination of ischemic damage secondary to anemia and prolonged hypotension and extensive leukemic infiltration. Markedly rapid decrease in ejection fraction from 66% to 33% also suggests the role of ischemia, since leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period. The diagnosis was not suspected during life due to concomitant signs and symptoms of anemia, pulmonary infections, and pericardial and pleural effusions. The patient succumbed to cardiac failure.", + "summary_subclaims": [ + "This is the first reported case of neoplastic infiltration of the heart with associated myocardial necrosis in a patient with myelodysplasia.", + "The neoplastic infiltration was associated with unicellular and multifocal geographic areas of necrosis in the left ventricle and the interventricular septum.", + "Cardiac compromise in the patient was likely due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks, and myocardial necrosis.", + "Myocardial necrosis was most likely due to a combination of ischemic damage secondary to anemia and prolonged hypotension and extensive leukemic infiltration.", + "A markedly rapid decrease in ejection fraction from 66% to 33% suggests the role of ischemia.", + "Leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period.", + "The diagnosis was not suspected during life due to concomitant signs and symptoms of anemia, pulmonary infections, and pericardial and pleural effusions.", + "The patient succumbed to cardiac failure." + ] + }, + { + "id": "multiclinsum_test_3189_en.txt", + "fulltext": "A 36-year-old male came to our emergency room with a chief complaint of jaw stiffness that made him difficult to open his mouth. He also complained of having difficulty swallowing. No complaint of abdominal muscle stiffness or whole body spasms. He also did not complain about having palpitation, difficulty in breathing, excessive salivation, nor sweating. He admitted that he had a fever for 2 days and a fishing hook wound on his index right fingertip around 5 days prior. He had dental cavities and did not have history of TB in any form. The patient could not recall his tetanus immunization status.\n\nUpon examination in the emergency room, a slight fever was observed. Other vital signs were within normal limits. On neurological examination, we found meningismus, 2 cm trismus, abdominal spasm, opisthotonus posturing, and spontaneous muscle spasms without dysautonomia. No other neurological findings nor spinal deformity was observed. Laboratory findings showed a slight increase in leukocyte count (12,700 cell/μL), normal electrocardiogram (ECG), normal blood electrolyte and renal function, and no pneumonia in his chest x-ray.\n\nThe diagnosis was general tetanus Grade 3 Patel Joag, and he received intravenous metronidazol, human tetanus immunoglobulin, and tetanus toxoid. Benzodiazepine was used to control the spasms in titrated doses. He underwent wound care to eliminate the source of infection, but treatment for dental cavities was postponed due to his locked jaw condition. A tracheostomy was planned as part of the standard procedure, but the patient refused to get one.\n\nDuring hospitalization, spontaneous and stimulated spasms worsened, and he developed dysautonomia with tachycardia, hyperthermia, hyperhydration, and hypersalivation. On observation, no signs of myocarditis or prolonged Qtc in ECG were found.\n\nIn the third week of treatment, while his tetanus condition improved, the patient started to complain about motor weakness in both legs. On examination, we observed 4 out of 5 motor scales, in the British Medical Research Council’s (MRC) motor scale, and increased knee-jerk reflexes. Inspection showed painful bulging/gibbus on the patient’s back with no pathological reflexes. The findings did not fit features of vertebral compression fracture due to tetanus which is usually mid-thoracic and painless.\n\nThe patient underwent a vertebral x-ray and magnetic resonance imaging (MRI). X-ray images showed a wedge-shaped fracture at the 11th-12th thoracic vertebrae. MRI images showed a compression fracture of 11th-12th thoracic vertebrae with gibbus and change of body intensity that compressed the spinal canal and pressed the spinal cord. Inhomogeneous vertebral body intensity changes in the 11th-12th thoracic vertebrae and the intervertebral disc were also observed, which was in line with the diagnosis of spondylosis TB and spondylodiscitis TB.\n\nA thorough history taking following the MRI revealed a history of backache for 3 years, presumably due to spinal TB. On a deeper anamnesis, it was revealed that he had the diagnosis of spinal TB and had received TB treatment for several months, but he did not realize that the present condition might be related to that.\n\nTreatment for spinal TB was then started using a standard regimen. A consultation for spinal surgery was made, but the patient refused to get operated. After 27 days of hospitalization, the patient recovered from tetanus and went home with 4 on the MRC motor scale. At follow-up, 3 months later, the patient has returned to his routine activity as a food hawker with no motor deficits.", + "fulltext_subclaims": [ + "The patient is a 36-year-old male.", + "He came to the emergency room with jaw stiffness that made him difficult to open his mouth.", + "He also complained of difficulty swallowing.", + "He did not complain of abdominal muscle stiffness.", + "He did not complain of whole body spasms.", + "He admitted to having a fever for 2 days.", + "He had a fishing hook wound on his index right fingertip around 5 days prior.", + "He had dental cavities.", + "He did not have a history of TB in any form.", + "He could not recall his tetanus immunization status.", + "Upon examination, a slight fever was observed.", + "Neurological examination found meningismus.", + "Neurological examination found 2 cm trismus.", + "Neurological examination found abdominal spasm.", + "Neurological examination found opisthotonus posturing.", + "Neurological examination found spontaneous muscle spasms.", + "No dysautonomia was observed.", + "Laboratory findings showed a slight increase in leukocyte count (12,700 cell/μL).", + "The diagnosis was general tetanus Grade 3 Patel Joag.", + "He received intravenous metronidazol.", + "He received human tetanus immunoglobulin.", + "He received tetanus toxoid.", + "Benzodiazepine was used to control the spasms in titrated doses.", + "He underwent wound care to eliminate the source of infection.", + "Treatment for dental cavities was postponed due to his locked jaw condition.", + "A tracheostomy was planned as part of the standard procedure.", + "The patient refused to get a tracheostomy.", + "During hospitalization, spontaneous and stimulated spasms worsened.", + "He developed dysautonomia with tachycardia.", + "He developed dysautonomia with hyperthermia.", + "He developed dysautonomia with hyperhydration.", + "He developed dysautonomia with hypersalivation.", + "No signs of myocarditis were found.", + "No prolonged Qtc in ECG was found.", + "In the third week of treatment, the patient started to complain about motor weakness in both legs.", + "On examination, 4 out of 5 motor scales were observed in the British Medical Research Council’s (MRC) motor scale.", + "Increased knee-jerk reflexes were observed.", + "Painful bulging/gibbus on the patient’s back was observed.", + "The findings did not fit features of vertebral compression fracture due to tetanus.", + "The patient underwent a vertebral x-ray.", + "X-ray images showed a wedge-shaped fracture at the 11th-12th thoracic vertebrae.", + "MRI images showed a compression fracture of 11th-12th thoracic vertebrae with gibbus.", + "MRI images showed change of body intensity that compressed the spinal canal and pressed the spinal cord.", + "Inhomogeneous vertebral body intensity changes in the 11th-12th thoracic vertebrae and the intervertebral disc were observed.", + "The diagnosis was spondylosis TB and spondylodiscitis TB.", + "A thorough history taking following the MRI revealed a history of backache for 3 years.", + "It was revealed that he had the diagnosis of spinal TB.", + "It was revealed that he had received TB treatment for several months.", + "Treatment for spinal TB was then started using a standard regimen.", + "A consultation for spinal surgery was made.", + "The patient refused to get operated.", + "After 27 days of hospitalization, the patient recovered from tetanus.", + "At follow-up, 3 months later, the patient has returned to his routine activity as a food hawker.", + "At follow-up, 3 months later, the patient has no motor deficits." + ], + "summary": "A 36-year-old male was brought to our hospital with jaw stiffness, accompanied by fever. A history of dental cavities was present, and 5 days prior, he experienced a fishing hook wound on his right index finger. There was no history of TB. Physical examination showed meningismus, 2 cm trismus, abdominal spasm, opisthotonus, and spontaneous muscle spasms, without dysautonomia. In the third week of hospitalization, while his tetanus condition improved, he complained of weakness in both legs. A thorough history taking revealed a history of backache for 3 years. A wedge-shaped fracture on his 11th and 12th thoracic vertebrae was observed on radiographic examination. A spinal TB diagnosis was made, and treatment was started. He refused to get spinal surgery, then went home with 4 out of 5 motor strength scale. After three months, he returned to his routine activity as a food hawker with no motor deficits.", + "summary_subclaims": [ + "The patient is a 36-year-old male.", + "He was brought to the hospital with jaw stiffness.", + "He had fever.", + "He had a history of dental cavities.", + "Five days prior, he experienced a fishing hook wound on his right index finger.", + "There was no history of TB.", + "Physical examination showed meningismus.", + "Physical examination showed 2 cm trismus.", + "Physical examination showed abdominal spasm.", + "Physical examination showed opisthotonus.", + "Physical examination showed spontaneous muscle spasms.", + "Physical examination showed no dysautonomia.", + "In the third week of hospitalization, while his tetanus condition improved, he complained of weakness in both legs.", + "A thorough history taking revealed a history of backache for 3 years.", + "A wedge-shaped fracture on his 11th and 12th thoracic vertebrae was observed on radiographic examination.", + "A spinal TB diagnosis was made.", + "Treatment was started.", + "He refused to get spinal surgery.", + "He went home with 4 out of 5 motor strength scale.", + "After three months, he returned to his routine activity as a food hawker.", + "He had no motor deficits." + ] + }, + { + "id": "multiclinsum_test_1670_en.txt", + "fulltext": "A 64-year-old woman with a past history of type 2 diabetes mellitus (under medical control by sitagliptin 100 mg per day for 5 years) experienced progressive voiding difficulty without fever for 2 mo. She had not undergone any previous urological or gynecological surgery. Urinary analysis showed pyuria, and she was admitted to our ward for further treatment. Bladder ultrasonography revealed urinary retention and a pelvic cystic lesion with a mass effect on the bladder . During admission, she also complained of perineal pain when she started to sit on a chair. Therefore, we arranged a pelvic computed tomography and the report showed a cystic lesion (9.1 cm) in the right lower pelvic region . Urologists were consulted and urodynamic studies were arranged. Uroflowmetry revealed an interrupted flow pattern with elevated post-void residual urine. Video urodynamics showed fair cystometric capacity and detrusor contraction, but the sphincter did not open during the examination. The results of the examinations all supported a diagnosis of bladder outlet obstruction due to a pelvic anatomical lesion. We consulted a gynecological expert, and a mass bulging from the right vaginal wall was found during pelvic examination. Transvaginal ultrasound revealed a pelvic cystic lesion originated from the vaginal wall. A vaginal abscess causing voiding dysfunction was diagnosed.", + "fulltext_subclaims": [ + "The patient is a 64-year-old woman.", + "She has a past history of type 2 diabetes mellitus.", + "She is under medical control by sitagliptin 100 mg per day.", + "She has had progressive voiding difficulty without fever for 2 mo.", + "She had not undergone any previous urological or gynecological surgery.", + "Urinary analysis showed pyuria.", + "Bladder ultrasonography revealed urinary retention.", + "Bladder ultrasonography revealed a pelvic cystic lesion with a mass effect on the bladder.", + "Pelvic computed tomography showed a cystic lesion (9.1 cm) in the right lower pelvic region.", + "Uroflowmetry revealed an interrupted flow pattern.", + "Uroflowmetry revealed elevated post-void residual urine.", + "Video urodynamics showed fair cystometric capacity.", + "Video urodynamics showed fair detrusor contraction.", + "The sphincter did not open during the video urodynamics examination.", + "The results of the examinations all supported a diagnosis of bladder outlet obstruction due to a pelvic anatomical lesion.", + "A mass bulging from the right vaginal wall was found during pelvic examination.", + "Transvaginal ultrasound revealed a pelvic cystic lesion originated from the vaginal wall.", + "A vaginal abscess causing voiding dysfunction was diagnosed." + ], + "summary": "We presented a case of vaginal abscess that caused voiding dysfunction without surgery history. A 64-year-old woman had a past history of type 2 diabetes mellitus. She came to our clinic following urinary difficulty with perineal tenderness. Bladder ultrasonography revealed a pelvic cystic lesion with a mass effect on the bladder. The presence of a vaginal abscess was suspected following pelvic examination and transvaginal ultrasound. After transvaginal drainage of the vaginal abscess and a full course of antibiotic treatment, she recovered well without any urination symptoms.", + "summary_subclaims": [ + "We presented a case of vaginal abscess that caused voiding dysfunction without surgery history.", + "The patient was a 64-year-old woman.", + "She had a past history of type 2 diabetes mellitus.", + "She came to our clinic following urinary difficulty with perineal tenderness.", + "Bladder ultrasonography revealed a pelvic cystic lesion with a mass effect on the bladder.", + "The presence of a vaginal abscess was suspected following pelvic examination and transvaginal ultrasound.", + "Transvaginal drainage of the vaginal abscess was performed.", + "A full course of antibiotic treatment was administered.", + "She recovered well without any urination symptoms." + ] + }, + { + "id": "multiclinsum_test_2498_en.txt", + "fulltext": "A 35-year-old male known epileptic, presented with altered sensorium for the past 2 days. On local examination, a 5 × 3 cm irregular bony swelling noted on the left forehead. There was no focal neurological deficit and no signs of meningeal irritation. Computed tomography (CT) of the brain plain showed a calcified lesion in the left frontal region along with ventriculomegaly and a huge cystic lesion in the left frontal region . Magnetic resonance imaging (MRI) revealed a lobulated irregular lesion causing mild compression on the underlying brain parenchyma. There was marked dilation of ventricles with transependymal seepage suggesting high-pressure hydrocephalus [ and ]. Patient was shunted immediately and clear cerebrospinal fluid (CSF) under high pressure was obtained. Routine analysis of CSF showed pleocytosis, with negative cultures. Patient postoperative CT scan showed tension pneumocephalus .\nCT bone window was done, which elaborated details of osteoma [-]. A left frontal craniotomy with free bone flap was done . About 5 × 2.5 cm irregular hard bony growth found disrupting the underlying dura . The cystic lesion was accessed through dural defect, thin clear mucoid substance drained and excised completely. There was no communication between cyst and ventricle at any point. Remaining osteoma was excised and sinus ostia was plugged with muscle piece. The dural defect was repaired and further reinforced with Dietz pericranial flap. Postoperatively patient did well, scans were satisfactory and no CSF leakage was found. On the 5th day, the patient developed fever and neck rigidity. A moderate growth of Colistin-sensitive Klebsiella species and Acinetobacter were cultured from CSF. A 2 week course of Colistin resulted in clinical improvement and patient was discharged home. Histopathology report showed a tumor with typical features of osteoma. Currently the patient is in follow-up, fits are controlled with oral sodium valproate.", + "fulltext_subclaims": [ + "A 35-year-old male known epileptic presented with altered sensorium for the past 2 days.", + "On local examination, a 5 × 3 cm irregular bony swelling was noted on the left forehead.", + "There was no focal neurological deficit.", + "There were no signs of meningeal irritation.", + "Computed tomography (CT) of the brain plain showed a calcified lesion in the left frontal region.", + "Computed tomography (CT) of the brain plain showed ventriculomegaly.", + "Computed tomography (CT) of the brain plain showed a huge cystic lesion in the left frontal region.", + "Magnetic resonance imaging (MRI) revealed a lobulated irregular lesion causing mild compression on the underlying brain parenchyma.", + "There was marked dilation of ventricles with transependymal seepage suggesting high-pressure hydrocephalus.", + "Patient was shunted immediately.", + "Clear cerebrospinal fluid (CSF) under high pressure was obtained.", + "Routine analysis of CSF showed pleocytosis.", + "CSF cultures were negative.", + "Postoperative CT scan showed tension pneumocephalus.", + "CT bone window was done, which elaborated details of osteoma.", + "A left frontal craniotomy with free bone flap was done.", + "About 5 × 2.5 cm irregular hard bony growth was found disrupting the underlying dura.", + "The cystic lesion was accessed through dural defect.", + "Thin clear mucoid substance was drained and excised completely.", + "There was no communication between cyst and ventricle at any point.", + "Remaining osteoma was excised.", + "Sinus ostia was plugged with muscle piece.", + "The dural defect was repaired.", + "The dural defect was further reinforced with Dietz pericranial flap.", + "Postoperatively, the patient did well.", + "Scans were satisfactory.", + "No CSF leakage was found.", + "On the 5th day, the patient developed fever.", + "On the 5th day, the patient developed neck rigidity.", + "A moderate growth of Colistin-sensitive Klebsiella species was cultured from CSF.", + "A moderate growth of Acinetobacter was cultured from CSF.", + "A 2 week course of Colistin resulted in clinical improvement.", + "The patient was discharged home.", + "Histopathology report showed a tumor with typical features of osteoma.", + "The patient is currently in follow-up.", + "Fits are controlled with oral sodium valproate." + ], + "summary": "A 35-year-old known epileptic, for the past 5 years, presented with altered sensorium for the past 2 days. Computed tomography (CT) of the brain plain showed ventriculomegaly and cystic lesion in the left frontal lobe adjacent to a calvarial osteoma. A ventriculoperitoneal (VP) shunt was done which resulted in tension pneumocephalus and led us to discover the origin of osteoma from the left frontal sinus on CT functional endoscopic sinus surgery (FESS) protocol. He underwent left frontal craniotomy. The osteoma and mucocele were excised completely and watertight primary dural closure was done. Postoperative meningitis was treated with antibiotics according to the culture report.", + "summary_subclaims": [ + "The patient is a 35-year-old known epileptic.", + "The patient had altered sensorium for the past 2 days.", + "CT of the brain plain showed ventriculomegaly.", + "CT of the brain plain showed a cystic lesion in the left frontal lobe.", + "A ventriculoperitoneal shunt was done.", + "The VP shunt resulted in tension pneumocephalus.", + "The origin of the osteoma was from the left frontal sinus.", + "The patient underwent left frontal craniotomy.", + "The osteoma and mucocele were excised completely.", + "Watertight primary dural closure was done.", + "Postoperative meningitis was treated with antibiotics.", + "Antibiotics were given according to the culture report." + ] + }, + { + "id": "multiclinsum_test_2581_en.txt", + "fulltext": "A 56-year-old woman with no infectious history was evaluated for palpitation. She had regular pulse rhythm and no heart murmur. Electrocardiography, Holter, electrocardiography, and chest X-ray findings were normal. Transthoracic echocardiography revealed an 8- × 8-mm mass on the posterior side of the anterior mitral leaflet with minimal mitral insufficiency . The left ventricular motion and dimensions were normal. Transesophageal echocardiography demonstrated similar findings. Computed tomography showed no systemic embolism. Because a valve tumor was suspected, surgical resection was attempted to prevent a possible systemic embolism. During surgery, we found that the lesion was not a tumor, but an aneurysm-like bulge on the anterior leaflet without chorda elongation . Triangular resection and ring annuloplasty were performed, and the patient’s postoperative course was uneventful. Pathological examination showed myxomatous change, fibrosis, and hyalinization, confirming a diagnosis of degenerative disease. Now, her condition has been good without any mitral valve abnormality including regurgitation at postoperative 10 months.", + "fulltext_subclaims": [ + "The patient is a 56-year-old woman.", + "She had no infectious history.", + "She was evaluated for palpitation.", + "She had regular pulse rhythm.", + "Electrocardiography findings were normal.", + "Holter findings were normal.", + "Chest X-ray findings were normal.", + "Transthoracic echocardiography revealed an 8- × 8-mm mass on the posterior side of the anterior mitral leaflet.", + "The left ventricular motion and dimensions were normal.", + "Transesophageal echocardiography demonstrated similar findings.", + "Computed tomography showed no systemic embolism.", + "Surgical resection was attempted to prevent a possible systemic embolism.", + "During surgery, the lesion was found to be an aneurysm-like bulge on the anterior leaflet without chorda elongation.", + "Triangular resection and ring annuloplasty were performed.", + "The patient’s postoperative course was uneventful.", + "Pathological examination showed myxomatous change, fibrosis, and hyalinization.", + "The diagnosis was confirmed as degenerative disease.", + "Her condition has been good without any mitral valve abnormality including regurgitation at postoperative 10 months." + ], + "summary": "A 56-year-old woman was evaluated for palpitation. Echocardiography revealed an 8- mm mass on the anterior mitral leaflet with minimal mitral insufficiency. Resection of the valve tumor was attempted to prevent a possible embolism. However, the lesion was not a tumor, but an aneurysm-like bulge on the anterior leaflet without chorda elongation. Triangular resection and ring annuloplasty were performed. The patient's postoperative course was uneventful. Pathological examination revealeddegenerative disease.", + "summary_subclaims": [ + "The patient was a 56-year-old woman.", + "The patient was evaluated for palpitation.", + "Echocardiography revealed an 8-mm mass on the anterior mitral leaflet.", + "Echocardiography showed minimal mitral insufficiency.", + "Resection of the valve tumor was attempted to prevent a possible embolism.", + "The lesion was not a tumor.", + "The lesion was an aneurysm-like bulge on the anterior leaflet.", + "The lesion had no chorda elongation.", + "Triangular resection and ring annuloplasty were performed.", + "The patient's postoperative course was uneventful.", + "Pathological examination revealed degenerative disease." + ] + }, + { + "id": "multiclinsum_test_55_en.txt", + "fulltext": "A 56 year old male presented with a non tender hard atrophic left testicle. The rest of the examination was normal. There had been no previous scrotal surgery or trauma.\nTumour markers including lactate dehydrogenase (LDH), human chorionic gonadotrophin (HCG), alpha fetoprotein (AFP) and prostate specific antigen (PSA) were normal. His total white cell count was normal. An ultrasound of the scrotum demonstrated a localised tumour of the testis. Chest x-ray was normal. A standard left radical orchidectomy was performed by the inguinal approach. The tumour appeared to be confined to the upper pole of the testis and was clinically described as T1 or T2. Macroscopic histological examination suggested no involvement of the tunica albuginea, epididymis or spermatic cord. Microscopic examination demonstrated infiltration of the testis by uniform ovoid cells with clear cytoplasm, vesicular nuclei and prominent nucleoli consistent with seminoma . Tumour involved the tunica albuginea but did not extend through it. There was no vascular invasion. Surprisingly, seminoma cells were present beneath the epithelial lining of the vas deferans extending to the spermatic cord resection margin but nowhere else within the spermatic cord. . The microscopic slides gave the appearance of sub epithelial spread of seminoma cells along the vas deferans. Other structures in the spermatic cord were not involved.\nA post operative CT scan demonstrated two separate masses. A 2.8 cm by 2.3 cm central abdominal mesenteric mass and a 7.6 cm by 5.4 cm irregular heterogeneous lobulated soft tissue mass within the pelvis arising from the prostate and extending into the mesorectal fascia. There were no enlarged retroperitoneal, pelvic, inguinal or thoracic lymph nodes. . The chest CT scan was normal. The patient has received chemotherapy and is currently under follow up according to standard EUA guidelines. There is no evidence of residual or recurrent disease. The CT scan performed after completion of the course of chemotherapy demonstrated complete resolution of the two metastatic masses. .", + "fulltext_subclaims": [ + "A 56 year old male presented with a non tender hard atrophic left testicle.", + "The rest of the examination was normal.", + "There had been no previous scrotal surgery or trauma.", + "Tumour markers including lactate dehydrogenase (LDH), human chorionic gonadotrophin (HCG), alpha fetoprotein (AFP) and prostate specific antigen (PSA) were normal.", + "His total white cell count was normal.", + "An ultrasound of the scrotum demonstrated a localised tumour of the testis.", + "Chest x-ray was normal.", + "A standard left radical orchidectomy was performed by the inguinal approach.", + "The tumour appeared to be confined to the upper pole of the testis and was clinically described as T1 or T2.", + "Macroscopic histological examination suggested no involvement of the tunica albuginea, epididymis or spermatic cord.", + "Microscopic examination demonstrated infiltration of the testis by uniform ovoid cells with clear cytoplasm, vesicular nuclei and prominent nucleoli consistent with seminoma.", + "Tumour involved the tunica albuginea but did not extend through it.", + "There was no vascular invasion.", + "Seminoma cells were present beneath the epithelial lining of the vas deferans extending to the spermatic cord resection margin but nowhere else within the spermatic cord.", + "The microscopic slides gave the appearance of sub epithelial spread of seminoma cells along the vas deferans.", + "Other structures in the spermatic cord were not involved.", + "A post operative CT scan demonstrated two separate masses.", + "A 2.8 cm by 2.3 cm central abdominal mesenteric mass was present.", + "A 7.6 cm by 5.4 cm irregular heterogeneous lobulated soft tissue mass within the pelvis arising from the prostate and extending into the mesorectal fascia was present.", + "There were no enlarged retroperitoneal, pelvic, inguinal or thoracic lymph nodes.", + "The chest CT scan was normal.", + "The patient has received chemotherapy.", + "The patient is currently under follow up according to standard EUA guidelines.", + "There is no evidence of residual or recurrent disease.", + "The CT scan performed after completion of the course of chemotherapy demonstrated complete resolution of the two metastatic masses." + ], + "summary": "We present a case report of testicular seminoma in a 56 year old man with previously unreported histological findings. In this case seminoma tumour cells did not appear to have spread by the expected lymphatic route. There was no involvement of retro-peritoneal para-aortic lymph nodes. The tumour appeared to have spread directly along the vas deferans in the sub epithelial plane to the mesenteric lymph nodes.", + "summary_subclaims": [ + "This is a case report of testicular seminoma in a 56 year old man.", + "The case had previously unreported histological findings.", + "Seminoma tumour cells did not appear to have spread by the expected lymphatic route.", + "There was no involvement of retro-peritoneal para-aortic lymph nodes.", + "The tumour appeared to have spread directly along the vas deferens in the sub epithelial plane.", + "The tumour spread to the mesenteric lymph nodes." + ] + }, + { + "id": "multiclinsum_test_225_en.txt", + "fulltext": "A 74-year-old Japanese female patient with a history of ischemic heart disease, nonvalvular atrial fibrillation, cerebral infarction, chronic kidney disease, and hypothyroidism was brought to the emergency department after a cardiac arrest at home. After a few minutes of manual CPR by her family and paramedics, mechanical CPR was initiated using the Lund University Cardiopulmonary Assist System-2 device (Physio-Control Inc.). The patient was defibrillated twice for ventricular fibrillation. She received multiple doses of epinephrine, and spontaneous circulation returned after 29 min of mechanical CPR. The device was used in its appropriate position.\nHowever, as pulseless ventricular tachycardia was still observed, cardiac support with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. Coronary angiography revealed no new lesions in the coronary arteries. A noncontrast CT scan was carried out to investigate the cause of cardiac arrest. This revealed multiple bilateral anterior rib fractures due to the chest compressions, with no evidence of other injuries . The cause of the arrest was considered to be hypokalemia (admission level K = 2.6 mmol/L) induced by multiple diuretic drugs. The patient was admitted to the intensive care unit for continued resuscitation. Furthermore, she received continuous infusions of unfractionated heparin based on active coagulation time. She was given prasugrel and apixaban because of her atrial fibrillation and high risk of stent thrombosis.\nOn hospital day 3, her blood pressure gradually decreased, and ECMO flow could not be maintained the following day. The patient had already received more than 20 units of blood products and was on a high-dose vasopressor. Blood examination revealed progressive coagulation abnormalities . The results were as follows: activated partial thromboplastin time, 136 s; prothrombin time activity, 31%; and platelet count, 25 × 109/L. Abdominal ultrasound revealed an echo-free space around the liver and spleen. An emergency laparotomy was carried out due to the massive bloody ascites observed on contrast-enhanced CT . Intraoperatively, a grade 2 splenic injury (according to the American Association for the Surgery of Trauma) was observed with a capsular tear and a 2 cm laceration at the inferior pole. The spleen was adherent to the retroperitoneum and diaphragm. The abdomen was temporarily closed using an open negative-pressure therapy system, ABThera (KCI). The volume of blood loss was greater than 10 L. As the patient was hemodynamically stable the next day, VA-ECMO was discontinued. Her coagulation abnormalities were resolved after management with the interruption of antithrombotic agents, surgical hemostasis, and blood transfusions. Abdominal closure was achieved on day 6. Histopathological examination of the excised splenic tissues was unremarkable. Tracheostomy was carried out on day 15, she was discharged from the intensive care unit on day 26, and transferred to a rehabilitation hospital on day 87 with no neurological deficits.", + "fulltext_subclaims": [ + "The patient was a 74-year-old Japanese female.", + "She had a history of ischemic heart disease.", + "She had nonvalvular atrial fibrillation.", + "She had cerebral infarction.", + "She had chronic kidney disease.", + "She had hypothyroidism.", + "She was brought to the emergency department after a cardiac arrest at home.", + "Mechanical CPR was initiated using the Lund University Cardiopulmonary Assist System-2 device.", + "The patient was defibrillated twice for ventricular fibrillation.", + "She received multiple doses of epinephrine.", + "Spontaneous circulation returned after 29 min of mechanical CPR.", + "The device was used in its appropriate position.", + "Pulseless ventricular tachycardia was still observed.", + "Cardiac support with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated.", + "Coronary angiography revealed no new lesions in the coronary arteries.", + "A noncontrast CT scan was carried out to investigate the cause of cardiac arrest.", + "The CT scan revealed multiple bilateral anterior rib fractures due to the chest compressions.", + "There was no evidence of other injuries.", + "The cause of the arrest was considered to be hypokalemia (admission level K = 2.6 mmol/L).", + "The hypokalemia was induced by multiple diuretic drugs.", + "The patient was admitted to the intensive care unit for continued resuscitation.", + "She received continuous infusions of unfractionated heparin based on active coagulation time.", + "She was given prasugrel.", + "She was given apixaban because of her atrial fibrillation and high risk of stent thrombosis.", + "On hospital day 3, her blood pressure gradually decreased.", + "ECMO flow could not be maintained the following day.", + "The patient had already received more than 20 units of blood products.", + "She was on a high-dose vasopressor.", + "Blood examination revealed progressive coagulation abnormalities.", + "The activated partial thromboplastin time was 136 s.", + "The prothrombin time activity was 31%.", + "The platelet count was 25 × 109/L.", + "Abdominal ultrasound revealed an echo-free space around the liver and spleen.", + "An emergency laparotomy was carried out due to the massive bloody ascites observed on contrast-enhanced CT.", + "Intraoperatively, a grade 2 splenic injury was observed.", + "The injury was according to the American Association for the Surgery of Trauma.", + "There was a capsular tear and a 2 cm laceration at the inferior pole.", + "The spleen was adherent to the retroperitoneum and diaphragm.", + "The abdomen was temporarily closed using an open negative-pressure therapy system, ABThera.", + "The volume of blood loss was greater than 10 L.", + "VA-ECMO was discontinued as the patient was hemodynamically stable the next day.", + "Her coagulation abnormalities were resolved after management with the interruption of antithrombotic agents, surgical hemostasis, and blood transfusions.", + "Abdominal closure was achieved on day 6.", + "Histopathological examination of the excised splenic tissues was unremarkable.", + "Tracheostomy was carried out on day 15.", + "She was discharged from the intensive care unit on day 26.", + "She was transferred to a rehabilitation hospital on day 87.", + "She had no neurological deficits." + ], + "summary": "Cardiopulmonary resuscitation was carried out using a mechanical chest compression device in a 74-year-old Japanese female patient who underwent cardiac arrest. Computed tomography postresuscitation revealed bilateral anterior rib fractures. Other traumatic findings were not observed. Coronary angiography revealed no new lesions; the cause of the arrest was hypokalemia. She received mechanical support with venoarterial extracorporeal membrane oxygenation and multiple antithrombotic agents. Her hemodynamic and coagulative condition became life-threatening on day 4; abdominal ultrasound revealed massive bloody ascites. Only a minor splenic laceration was observed intraoperatively, despite massive bleeding. Furthermore, her condition stabilized after splenectomy and blood transfusion. Venoarterial extracorporeal membrane oxygenation was discontinued on day 5.", + "summary_subclaims": [ + "Cardiopulmonary resuscitation was carried out using a mechanical chest compression device in a 74-year-old Japanese female patient who underwent cardiac arrest.", + "Computed tomography postresuscitation revealed bilateral anterior rib fractures.", + "Other traumatic findings were not observed.", + "Coronary angiography revealed no new lesions.", + "The cause of the arrest was hypokalemia.", + "She received mechanical support with venoarterial extracorporeal membrane oxygenation and multiple antithrombotic agents.", + "Her hemodynamic and coagulative condition became life-threatening on day 4.", + "Abdominal ultrasound revealed massive bloody ascites.", + "Only a minor splenic laceration was observed intraoperatively, despite massive bleeding.", + "Her condition stabilized after splenectomy and blood transfusion.", + "Venoarterial extracorporeal membrane oxygenation was discontinued on day 5." + ] + }, + { + "id": "multiclinsum_test_1281_en.txt", + "fulltext": "A 33-year-old female presented 3 months postpartum with a headache of moderate severity and progressive visual loss in both eyes. On examination, the patient's Glasgow coma scale (GCS) was 15/15. Visual field examination showed left homonymous incomplete hemianopia. Her visual acuity was 20/25 in the right eye and 20/30 in the left eye. Her discs and macula were healthy bilaterally. Extraocular movements were intact and pupils were reactive. The rest of her examination was unremarkable. Complete endocrine workup was normal.\nMagnetic resonance imaging (MRI) revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure measuring 31 × 30 × 90 mm on T1-weighted images. There was mass effect on the adjacent hypothalamus and third ventricle displacing them toward the left and superiorly in addition to the optic pathway. The pituitary stalk was displaced toward the left. The lesion encased the right posterior cerebral artery and displaced the right carotid artery laterally . Computed tomography (CT) arteriography demonstrated a completely thrombosed center. The imaging findings were compatible with suprasellar CM.\nThe patient underwent right frontal craniotomy and gross total resection of her suprasellar intrachiasmatic large infiltrative hemorrhagic CM. Organizing blood clots with reactive fibrohistiocytic and inflammatory reaction admixed with some ectatic vascular channels suggestive of a vascular malformation were noted. There were small foci admixed with granulation tissue, showing some dilated cavernous spaces that would be compatible with a vascular malformation such as cavernous angioma. On immunohistochemistry, the lesion was CD163+, CD20 rare, CD3+, CD34+, CD31+, CD38+, CTK−, EMA plasma cells, GFAP−, S100 dendritic cells, SMA vascular smooth muscle.\nThe patient had an uneventful operative course. Her visual acuity improved to 20/20 in both eyes. Extraocular muscles showed mild limitation of both eyes in an upward gaze. Otherwise, she was stable with no neurological deficits. Follow-up MRI at 12 months revealed complete removal of the suprasellar hemorrhagic CM with no evidence of a residual lesion or recurrence .", + "fulltext_subclaims": [ + "The patient was a 33-year-old female.", + "The patient was 3 months postpartum.", + "The patient had a headache of moderate severity.", + "The patient had progressive visual loss in both eyes.", + "The patient's Glasgow coma scale (GCS) was 15/15.", + "Visual field examination showed left homonymous incomplete hemianopia.", + "The patient's visual acuity was 20/25 in the right eye.", + "The patient's visual acuity was 20/30 in the left eye.", + "The patient's discs and macula were healthy bilaterally.", + "Extraocular movements were intact.", + "Pupils were reactive.", + "The rest of the patient's examination was unremarkable.", + "Complete endocrine workup was normal.", + "MRI revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure.", + "The lesion measured 31 × 30 × 90 mm on T1-weighted images.", + "There was mass effect on the adjacent hypothalamus and third ventricle.", + "The lesion displaced the optic pathway.", + "The pituitary stalk was displaced toward the left.", + "The lesion encased the right posterior cerebral artery.", + "The lesion displaced the right carotid artery laterally.", + "CT arteriography demonstrated a completely thrombosed center.", + "The imaging findings were compatible with suprasellar CM.", + "The patient underwent right frontal craniotomy.", + "The patient had gross total resection of her suprasellar intrachiasmatic large infiltrative hemorrhagic CM.", + "Organizing blood clots with reactive fibrohistiocytic and inflammatory reaction were noted.", + "There were some ectatic vascular channels suggestive of a vascular malformation.", + "There were small foci admixed with granulation tissue.", + "The lesion showed some dilated cavernous spaces compatible with a vascular malformation such as cavernous angioma.", + "The lesion was CD163+.", + "The lesion was CD20 rare.", + "The lesion was CD3+.", + "The lesion was CD34+.", + "The lesion was CD31+.", + "The lesion was CD38+.", + "The lesion was CTK−.", + "The lesion showed EMA plasma cells.", + "The lesion was GFAP−.", + "The lesion showed S100 dendritic cells.", + "The lesion was SMA vascular smooth muscle.", + "The patient had an uneventful operative course.", + "The patient's visual acuity improved to 20/20 in both eyes.", + "Extraocular muscles showed mild limitation of both eyes in an upward gaze.", + "The patient was stable with no neurological deficits.", + "Follow-up MRI at 12 months revealed complete removal of the suprasellar hemorrhagic CM.", + "There was no evidence of a residual lesion or recurrence." + ], + "summary": "The authors report a rare case of suprasellar optic pathway cavernous malformation in a 33-year-old female who presented with progressive visual loss. Her imaging revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure, causing mass effect on the adjacent hypothalamus and third ventricle displacing these structures. Gross total resection of the lesion was achieved utilizing a right frontal craniotomy approach. Histopathological examination confirmed the diagnosis of suprasellar chiasmal cavernous malformation.", + "summary_subclaims": [ + "The authors report a rare case of suprasellar optic pathway cavernous malformation in a 33-year-old female.", + "The patient presented with progressive visual loss.", + "Imaging revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure.", + "The lesion caused mass effect on the adjacent hypothalamus and third ventricle.", + "The lesion displaced the hypothalamus and third ventricle.", + "Gross total resection of the lesion was achieved.", + "The resection was performed utilizing a right frontal craniotomy approach.", + "Histopathological examination confirmed the diagnosis of suprasellar chiasmal cavernous malformation." + ] + }, + { + "id": "multiclinsum_test_1079_en.txt", + "fulltext": "A 41-year-old man with SIT since early childhood was referred to our hospital because of high serum carcinoembryonic antigen levels (6.0 µg/L). The patient had no surgical history. His body mass index was 24.3 kg/m2. Physical examination results were normal. All laboratory data were within the normal range, except for the tumor markers. Colonoscopy revealed a bulge at the orifice of the appendix, but pathological examination did not reveal any malignancy . Abdominal contrast-enhanced computed tomography (CT) showed complete “mirror-images” of the visceral organs . CT also showed appendiceal wall thickening, a cystic tumor with contrast effect, and an enlarged lymph node close to the tumor . CT and magnetic resonance imaging showed no solid component in the cystic tumor that would strongly suggest mucinous adenocarcinoma. The preoperative diagnosis was an appendiceal mucocele, which was considered a possible tumor such as low-grade appendiceal mucinous neoplasm (LAMN). We planned a laparoscopic-assisted ileocecal resection with D2 lymph-node dissection since the tumor was located at the root of the appendix with an enlarged lymph node. Preoperatively, we evaluated anatomical variations using 3D-CT, and no vascular anomalies except for completely inverted vessels were observed . In addition, we watched horizontally flipped videos of patients with normal anatomy undergoing similar operations to simulate mirror images and symmetrical procedures.\nUnder general anesthesia, the patient was placed in lithotomy position. In contrast to normal surgery, the operator stood on the patient’s right side, the first assistant on the left side, and the scopist between the legs . A laparoscope was inserted through the umbilical trocar, and the other four trocars were placed opposite to their usual placement as shown in Fig. . Additionally, a 12 mm trocar was placed in the operator’s right hand, and two monitors were placed at the patient’s head. One monitor showed original images, and the other showed horizontally flipped images that looked the same as the normal anatomy . The central monitor 1 displayed the original images for the surgeons to see them easily, because it is dangerous and difficult to move the forceps while looking at flipped images due to paradoxical movement of the instruments. Moreover, the images displayed on the monitors were exchanged according to the surgical situation. As needed, the operation was momentarily paused to check for the range of mobilized regions and to visualize important anatomical structures by watching the monitor that showed flipped images .\nLaparoscopy and intraperitoneal observation revealed transposition of the visceral organs, such as the liver, gallbladder, stomach, and colon. The ileocecal resection procedure was performed using the retroperitoneal approach as usual. The small intestine was moved cranially to secure the surgical field, and we initiated ileocecal mobilization. We dissected the mesentery from the retroperitoneal tissue with a focus on the gonadal vessels and identified the transverse portion of the duodenum. Next, while dissecting along the descending portion of the duodenum , we dissected the lateral attachment of the colon to the left abdominal wall toward the cranial side and mobilized the hepatic flexure . Finally, we performed additional dissection around the duodenum and pancreatic head, completing the mobilization . Since D3 lymph-node dissection was not necessary, we divided the ileocolic vessels near its root without lymph node dissection around the superior mesenteric vein (SMV) and performed resection and reconstruction of the colon extracorporeally. In total, the operative time was 119 min, and the patient’s postoperative course was uneventful. Postoperative pathological examination revealed lymphoid follicles in the intestinal epithelium of the appendiceal orifice and inflamed appendiceal mucosa with neutrophils and eosinophils. No tumor cells suggestive of LAMN or malignancy were observed.\nRegarding laparoscopic surgical procedure for SIT, it was unclear how far the mobilization proceeded due to the mirror image; however, during the procedure, we periodically examined the mobilization progression by momentarily pausing the operation to watch the monitor showing flipped images. Additionally, we noted the following differences between surgery in SIT and surgery in patients with normal anatomy: (1) operability involving large movements such as moving the small intestine and securing the surgical field (2) recognition of anatomies such as orientation of the gonadal vessels and duodenum, positional relationship between the hepatic flexure and duodenum, and the hepatic flexure in the upper left abdomen being closer than expected as compared to the splenic flexure in normal anatomy. In such situations, we were able to appropriately address any confusion and misrecognition by checking the flipped monitor . Additionally, this procedural method allowed for safe operation on important organs, such as the pancreatic head . To enable the readers to understand the procedure, a video of the surgery with flipped images has been attached as a Additional file : Video S1.", + "fulltext_subclaims": [ + "The patient was a 41-year-old man with situs inversus totalis since early childhood.", + "The patient was referred to the hospital because of high serum carcinoembryonic antigen levels (6.0 µg/L).", + "The patient had no surgical history.", + "The patient's body mass index was 24.3 kg/m2.", + "Physical examination results were normal.", + "All laboratory data were within the normal range, except for the tumor markers.", + "Colonoscopy revealed a bulge at the orifice of the appendix.", + "Pathological examination did not reveal any malignancy.", + "Abdominal contrast-enhanced computed tomography showed complete “mirror-images” of the visceral organs.", + "CT showed appendiceal wall thickening.", + "CT showed a cystic tumor with contrast effect.", + "CT showed an enlarged lymph node close to the tumor.", + "CT and magnetic resonance imaging showed no solid component in the cystic tumor that would strongly suggest mucinous adenocarcinoma.", + "The preoperative diagnosis was an appendiceal mucocele.", + "The preoperative diagnosis considered the possibility of low-grade appendiceal mucinous neoplasm (LAMN).", + "A laparoscopic-assisted ileocecal resection with D2 lymph-node dissection was planned.", + "Preoperatively, anatomical variations were evaluated using 3D-CT.", + "No vascular anomalies except for completely inverted vessels were observed.", + "Horizontally flipped videos of patients with normal anatomy undergoing similar operations were watched to simulate mirror images.", + "The patient was placed in lithotomy position under general anesthesia.", + "The operator stood on the patient’s right side.", + "The first assistant stood on the patient’s left side.", + "The scopist stood between the patient’s legs.", + "A laparoscope was inserted through the umbilical trocar.", + "The other four trocars were placed opposite to their usual placement.", + "A 12 mm trocar was placed in the operator’s right hand.", + "Two monitors were placed at the patient’s head.", + "One monitor showed original images.", + "The other monitor showed horizontally flipped images.", + "The central monitor 1 displayed the original images for the surgeons to see them easily.", + "The images displayed on the monitors were exchanged according to the surgical situation.", + "The operation was momentarily paused to check the range of mobilized regions.", + "The operation was momentarily paused to visualize important anatomical structures by watching the monitor showing flipped images.", + "Laparoscopy and intraperitoneal observation revealed transposition of the visceral organs.", + "The ileocecal resection procedure was performed using the retroperitoneal approach.", + "The small intestine was moved cranially to secure the surgical field.", + "Ileocecal mobilization was initiated.", + "The mesentery was dissected from the retroperitoneal tissue with a focus on the gonadal vessels.", + "The transverse portion of the duodenum was identified.", + "Dissection was performed along the descending portion of the duodenum.", + "The lateral attachment of the colon to the left abdominal wall was dissected toward the cranial side.", + "The hepatic flexure was mobilized.", + "Additional dissection was performed around the duodenum and pancreatic head.", + "The ileocolic vessels were divided near their root without lymph node dissection around the superior mesenteric vein.", + "The colon was resected and reconstructed extracorporeally.", + "The total operative time was 119 min.", + "The patient’s postoperative course was uneventful.", + "Postoperative pathological examination revealed lymphoid follicles in the intestinal epithelium of the appendiceal orifice.", + "Postoperative pathological examination revealed inflamed appendiceal mucosa with neutrophils and eosinophils.", + "No tumor cells suggestive of LAMN or malignancy were observed.", + "It was unclear how far the mobilization proceeded due to the mirror image.", + "The mobilization progression was periodically examined by momentarily pausing the operation to watch the monitor showing flipped images.", + "Differences between surgery in SIT and surgery in patients with normal anatomy included operability involving large movements.", + "Differences included recognition of anatomies such as orientation of the gonadal vessels and duodenum.", + "The hepatic flexure in the upper left abdomen was closer than expected as compared to the splenic flexure in normal anatomy.", + "Confusion and misrecognition were appropriately addressed by checking the flipped monitor.", + "The procedural method allowed for safe operation on important organs, such as the pancreatic head.", + "A video of the surgery with flipped images has been attached as Additional file: Video S1." + ], + "summary": "A 41-year-old man with SIT was diagnosed with an appendiceal tumor and underwent laparoscopic-assisted ileocecal resection. Preoperatively, we evaluated anatomical variations using 3D-computed tomography and simulated mirror images by watching flipped videos of patients with normal anatomy undergoing similar operations. During the operation, port placement and the surgeons' standing positions were reversed. Additionally, two monitors were placed at the patient's head, with one monitor showing original images, and the other showing flipped images that looked the same as the normal anatomy. We checked the range of the mobilized region and important anatomical structures by watching the flipped monitor as needed. The patient's postoperative course was uneventful.", + "summary_subclaims": [ + "The patient was a 41-year-old man with SIT.", + "The patient was diagnosed with an appendiceal tumor.", + "The patient underwent laparoscopic-assisted ileocecal resection.", + "Preoperatively, anatomical variations were evaluated using 3D-computed tomography.", + "Mirror images were simulated by watching flipped videos of patients with normal anatomy undergoing similar operations.", + "During the operation, port placement and the surgeons' standing positions were reversed.", + "Two monitors were placed at the patient's head.", + "One monitor showed original images.", + "The other monitor showed flipped images that looked the same as the normal anatomy.", + "The range of the mobilized region and important anatomical structures were checked by watching the flipped monitor as needed.", + "The patient's postoperative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_1057_en.txt", + "fulltext": "A 72-year-old man (height 168.5 cm, weight 72.4 kg, and body mass index 25.5 kg/m2) had type 2 diabetes mellitus and stage 4 chronic kidney disease (estimated glomerular filtration rate [eGFR] 28.0 mL/min/1.73 m2) before X-47 years. Other medical history included heart failure with reduced ejection fraction due to acute myocardial infarction, right lower extremity atherosclerosis obliterans, cataracts, and osteoporosis. He had no family history of diabetes, and no history of allergies and side reactions.\nHe underwent an emergent percutaneous coronary intervention at Mie University Hospital in X-5 years but did not achieve good glycemic control despite taking glimepiride 3 mg once daily, sitagliptin 50 mg once daily, and metformin 250 mg twice daily (fasting blood glucose level 327 mg/dL and hemoglobin A1c [HbA1c] 7.8%). His primary physician changed his antidiabetic medication to sitagliptin 50 mg once daily, mitiglinide 10 mg three times daily, and insulin glargine 10 units once daily, and he was subsequently discharged from the hospital for regular visits.\nThe patient’s daily dose of insulin glargine was increased from 10 to 12 units because of poor glycemic control (X-4 years; HbA1c 7.9%). Nevertheless, he did not obtain good glycemic control in X-3 years (HbA1c 8.2%). His primary physician confirmed negative findings of anti-glutamic acid decarboxylase antibody, C-peptide level of 2.9 ng/mL, and C-peptide index of 1.6. In X-2 years, voglibose 0.2 mg three times daily was added to the present regimen (HbA1c 8.1%). In X year (day 0), he orally received vadadustat 300 mg once daily with a diagnosis of renal anemia (hemoglobin 9.9 g/dL and HbA1c 7.4%). His eGFR was approximately 30 mL/min/1.73 m2 during the follow-up . The blood glucose mean (± standard deviation) over the last two weeks (days -14 to -1) was 108 ± 14 mg/dL before breakfast, 122 ± 24 mg/dL before lunch, and 158 ± 39 mg/dL before dinner . The prescribed medications on day 0 were sitagliptin 50 mg once daily, mitiglinide 10 mg three times daily, voglibose 0.2 mg three times daily, insulin glargine injection 12 units once daily, aspirin enteric tablets 100 mg once daily, rosuvastatin 10 mg once daily, esomeprazole 20 mg once daily, furosemide 20 mg once daily, carvedilol 10 mg twice daily, eplerenone 25 mg once daily, perindopril 2 mg once daily, and minodronic acid 50 mg every 4 weeks. There were no significant changes in medication history and lifestyle habits, such as diet and exercise, during treatment with vadadustat. Self-monitoring of blood glucose showed a decreasing tendency on day 18 after the start of vadadustat administration. He developed asymptomatic hypoglycemia on day 23 . The blood glucose level of the concomitant vadadustat period (days 0 to 23) was 94 ± 16 mg/dL before breakfast, 109 ± 20 mg/dL before lunch, and 126 ± 30 mg/dL before dinner . He called his outpatient attending physician and visited the hospital on the same day. This phenomenon was considered to be a result of the drug–drug interaction between sitagliptin and vadadustat via OAT3 inhibition, resulting in an enhanced hypoglycemic effect of sitagliptin and mitiglinide.\nThe blood glucose recovered to 121 ± 25 mg/dL before breakfast, 147 ± 38 mg/dL before lunch, and 161 ± 36 mg/dL before dinner after discontinuation of vadadustat (days 24 to 37) . On day 56, at the regular clinic visit, his medication was changed to the alternative HIF-PHD inhibitor, daprodustat 2 mg once daily, and dipeptidyl-peptidase-4 (DPP-4) inhibitor, linagliptin 5 mg once daily, which is not transported by OAT3. Thereafter, the blood glucose remained stable at 111 ± 19 mg/dL before breakfast, 119 ± 13 mg/dL before lunch, and 134 ± 32 mg/dL before dinner (days 57 to 70). On the drug interaction probability scale (DIPS), the drug–drug interaction between sitagliptin and vadadustat was scored at 5 points, classified as “probable” .", + "fulltext_subclaims": [ + "The patient was a 72-year-old man with type 2 diabetes mellitus and stage 4 chronic kidney disease before X-4 years.", + "The patient's estimated glomerular filtration rate was 28.0 mL/min/1.73 m2 before X-4 years.", + "The patient had heart failure with reduced ejection fraction due to acute myocardial infarction.", + "The patient had right lower extremity atherosclerosis obliterans.", + "The patient had no family history of diabetes.", + "The patient had no history of allergies and side reactions.", + "The patient underwent an emergent percutaneous coronary intervention at Mie University Hospital in X-5 years.", + "Before X-4 years, the patient was taking glimepiride 3 mg once daily, sitagliptin 50 mg once daily, and metformin 250 mg twice daily.", + "Before X-4 years, the patient's fasting blood glucose level was 327 mg/dL.", + "Before X-4 years, the patient's hemoglobin A1c was 7.8%.", + "The patient's antidiabetic medication was changed to sitagliptin 50 mg once daily, mitiglinide 10 mg three times daily, and insulin glargine 10 units once daily.", + "The patient was discharged from the hospital for regular visits after the medication change.", + "The patient's daily dose of insulin glargine was increased from 10 to 12 units in X-4 years.", + "In X-4 years, the patient's hemoglobin A1c was 7.9%.", + "In X-3 years, the patient's hemoglobin A1c was 8.2%.", + "The patient's anti-glutamic acid decarboxylase antibody test was negative.", + "The patient's C-peptide level was 2.9 ng/mL.", + "The patient's C-peptide index was 1.6.", + "In X-2 years, voglibose 0.2 mg three times daily was added to the present regimen.", + "In X-2 years, the patient's hemoglobin A1c was 8.1%.", + "On day 0, the patient was diagnosed with renal anemia.", + "On day 0, the patient's hemoglobin was 9.9 g/dL.", + "On day 0, the patient's hemoglobin A1c was 7.4%.", + "On day 0, the patient received vadadustat 300 mg once daily.", + "The patient's estimated glomerular filtration rate was approximately 30 mL/min/1.73 m2 during the follow-up.", + "The blood glucose mean before breakfast over the last two weeks was 108 ± 14 mg/dL.", + "The blood glucose mean before lunch over the last two weeks was 122 ± 24 mg/dL.", + "The blood glucose mean before dinner over the last two weeks was 158 ± 39 mg/dL.", + "On day 0, the patient was taking sitagliptin 50 mg once daily.", + "On day 0, the patient was taking mitiglinide 10 mg three times daily.", + "On day 0, the patient was taking voglibose 0.2 mg three times daily.", + "On day 0, the patient was taking insulin glargine injection 12 units once daily.", + "On day 0, the patient was taking aspirin enteric tablets 100 mg once daily.", + "On day 0, the patient was taking rosuvastatin 10 mg once daily.", + "On day 0, the patient was taking esomeprazole 20 mg once daily.", + "On day 0, the patient was taking furosemide 20 mg once daily.", + "On day 0, the patient was taking carvedilol 10 mg twice daily.", + "On day 0, the patient was taking eplerenone 25 mg once daily.", + "On day 0, the patient was taking perindopril 2 mg once daily.", + "On day 0, the patient was taking minodronic acid 50 mg every 4 weeks.", + "There were no significant changes in medication history during treatment with vadadustat.", + "There were no significant changes in lifestyle habits, such as diet and exercise, during treatment with vadadustat.", + "Self-monitoring of blood glucose showed a decreasing tendency on day 18 after the start of vadadustat administration.", + "The patient developed asymptomatic hypoglycemia on day 23.", + "The blood glucose level during the concomitant vadadustat period was 94 ± 16 mg/dL before breakfast.", + "The blood glucose level during the concomitant vadadustat period was 109 ± 20 mg/dL before lunch.", + "The blood glucose level during the concomitant vadadustat period was 126 ± 30 mg/dL before dinner.", + "The patient visited the hospital on day 23.", + "The phenomenon was considered to be a result of the drug–drug interaction between sitagliptin and vadadustat via OAT3 inhibition.", + "The drug–drug interaction resulted in an enhanced hypoglycemic effect of sitagliptin and mitiglinide.", + "The blood glucose recovered to 121 ± 25 mg/dL before breakfast after discontinuation of vadadustat.", + "The blood glucose recovered to 147 ± 38 mg/dL before lunch after discontinuation of vadadustat.", + "The blood glucose recovered to 161 ± 36 mg/dL before dinner after discontinuation of vadadustat.", + "On day 56, the patient's medication was changed to daprodustat 2 mg once daily.", + "On day 56, the patient's medication was changed to linagliptin 5 mg once daily.", + "The blood glucose remained stable at 111 ± 19 mg/dL before breakfast after the medication change.", + "The blood glucose remained stable at 119 ± 13 mg/dL before lunch after the medication change.", + "The blood glucose remained stable at 134 ± 32 mg/dL before dinner after the medication change.", + "The drug–drug interaction between sitagliptin and vadadustat was scored at 5 points on the drug interaction probability scale.", + "The drug–drug interaction between sitagliptin and vadadustat was classified as 'probable' on the drug interaction probability scale." + ], + "summary": "A 72-year-old man with type 2 diabetes mellitus had received sitagliptin 50 mg once daily and mitiglinide 10 mg three times daily over the last 3 years. He initiated vadadustat 300 mg once daily orally on day X owing to renal anemia (hemoglobin A1c: 7.4% and estimated glomerular filtration rate: 28.0 mL/min/1.73 m2). On day 23, he developed hypoglycemia with a blood glucose level of 67 mg/dL. The mean blood glucose level ± standard deviation was lower in the first 24 days of co-administration of vadadustat (before breakfast: 94 ± 14 mg/dL, before lunch: 109 ± 24 mg/dL, and before dinner: 126 ± 39 mg/dL) than in the last 2 weeks (before breakfast: 108 ± 14 mg/dL, before lunch: 122 ± 24 mg/dL, and before dinner: 158 ± 39 mg/dL). Considering the timing of the concomitant administration of vadadustat, hypoglycemia may have been caused by the drug-drug interaction between sitagliptin and vadadustat, and he discontinued treatment with vadadustat. The mean blood glucose levels improved two weeks after the discontinuation of vadadustat (before breakfast: 121 ± 25 mg/dL, before lunch: 147 ± 38 mg/dL, and before dinner: 161 ± 36 mg/dL). The drug interaction probability scale was classified as \"Probable\" (5 points).", + "summary_subclaims": [ + "The patient was a 72-year-old man with type 2 diabetes mellitus.", + "He had received sitagliptin 50 mg once daily and mitiglinide 10 mg three times daily over the last 3 years.", + "He initiated vadadustat 300 mg once daily orally on day X.", + "The reason for initiating vadadustat was renal anemia.", + "The hemoglobin A1c was 7.4%.", + "The estimated glomerular filtration rate was 28.0 mL/min/1.73 m2.", + "On day 23, he developed hypoglycemia with a blood glucose level of 67 mg/dL.", + "The mean blood glucose level ± standard deviation was lower in the first 24 days of co-administration of vadadustat.", + "The mean blood glucose level before breakfast was 94 ± 14 mg/dL in the first 24 days of co-administration.", + "The mean blood glucose level before breakfast was 108 ± 14 mg/dL in the last 2 weeks.", + "The mean blood glucose level before lunch was 109 ± 24 mg/dL in the first 24 days of co-administration.", + "The mean blood glucose level before lunch was 122 ± 24 mg/dL in the last 2 weeks.", + "The mean blood glucose level before dinner was 126 ± 39 mg/dL in the first 24 days of co-administration.", + "The mean blood glucose level before dinner was 158 ± 39 mg/dL in the last 2 weeks.", + "Hypoglycemia may have been caused by the drug-drug interaction between sitagliptin and vadadustat.", + "He discontinued treatment with vadadustat.", + "The mean blood glucose levels improved two weeks after the discontinuation of vadadustat.", + "The mean blood glucose level before breakfast was 121 ± 25 mg/dL two weeks after the discontinuation of vadadustat.", + "The mean blood glucose level before lunch was 147 ± 38 mg/dL two weeks after the discontinuation of vadadustat.", + "The mean blood glucose level before dinner was 161 ± 36 mg/dL two weeks after the discontinuation of vadadustat.", + "The drug interaction probability scale was classified as 'Probable'.", + "The drug interaction probability scale score was 5 points." + ] + }, + { + "id": "multiclinsum_test_1870_en.txt", + "fulltext": "A 1-year 9-month-old female patient with non-significant past medical or surgical history, a full-term product of a non-complicated vaginal delivery with no neonatal intensive care unit admissions was referred to our center for further investigations regarding the diagnosis of an intraabdominal mass versus an abdominal abscess. The patient complained of abdominal pain and fever for 10 days duration. The pain was located in the epigastric area radiating to left upper quadrant, and associated with nausea, vomiting and anorexia. The pain was severe enough to awaken the patient from her sleep. The fever was intermittent in nature with maximum recorded value of 39 °C orally, responded well to paracetamol. Upon physical examination, an epigastric tenderness was observed associated with left upper quadrant guarding to palpation. Otherwise, the abdomen was soft and lax. The suspected mass could not be palpated.\nLaboratory investigations , abdominal X-ray and ultrasonography were performed . Ultrasonography revealed a well-defined, multiloculated, cystic lesion seen in the epigastric region and extending into the left upper quadrant with foci of calcification seen with posterior acoustic enhancement, with no hyperemia seen on Doppler images. The largest locule measured about 4.8 × 4.0 × 5.6 cm seen in the epigastric region containing swirling debris. Findings highly suggest an organized abscess secondary to infected mesenteric cyst or a lymphangioma. Liver, spleen and pancreas were all homogenous with no focal lesions. The long axis of the liver and spleen was 8.7 and 6.7 cm, respectively. Both kidneys appear normal in size, shape and echotexture with no hydronephrosis. The long axis of the right and left kidneys was 7.2 and 7.1 cm, respectively. Gallbladder had a smooth outline with no stones. No intra- or extra-hepatic biliary dilatation were seen. Subsequent computed tomography (CT) imaging with intravenous contrast revealed a multiloculated thick enhancing-walled fluid collection seen in the mesentery anteriorly and extending to the left upper quadrant and flank region. The largest locule is seen in the anterior abdomen measuring 6.7 × 6.2 cm containing two tiny foci of calcifications which caused a mass effect to adjacent small and large bowel loops displacing them posteriorly and laterally. The lesion was associated with sub-centimetric enhancing locoregional lymph nodes with the largest measuring about 0.5 cm in the short axis. A mild amount of fluid was seen in the pelvis. CT scan finding along with ultrasonography results suggest an organized abscess secondary to infected mesenteric cyst or a lymphangioma. A trial of true-cut biopsies performed by an interventional radiologist was not informative in which the histopathological examination of three needle core biopsies measuring 1.5, 1.5 and 0.5 cm indicated fragments of fibrinoid material with no viable cells and composed of skeletal muscles and fibrous tissue, precluding proper diagnosis.\nA Multidisciplinary team decision was made to excise the mass by the pediatric surgery team. Intraoperative findings include : multiloculated fused cystic lesions (8.0 × 5.0 × 4.0 cm) on the descending mesocolon. Descending colon loops were healthy and viable. Complete excision of the mass was performed with preservation of the attached descending colon through a midline laparotomy incision. Histopathological examination of the excised mass revealed a variably sized thin-walled vascular spaces almost devoid of blood and containing pale pink fluid mostly representing lymph. Such spaces are surrounded by loose fibrous tissue with inflammatory cellular infiltrate (mainly eosinophils and plasma cells) with lymphoid follicles (A). The spaces are lined by a layer of endothelial cells highlighted by CD31 and CD34 immunohistochemical staining (B and C). No evidence of malignancy was observed.\nPostoperatively, a nasogastric (NG) tube was inserted, and the patient was on the following medication: vancomycin (165 mg, Q6h), piperacillin/tazobactam (1 g, Q6h), diclofenac suppositories (12.5 mg, Q12 h) and paracetamol (pro re nata). Medications were stopped at day 5 and the NG tube was removed at day 3 postoperatively. The patient was doing well, vitally stable, passed flatus on day 2, passed stool at day 4 and discharged after 5 days postoperatively. The patient was followed 1 week after the surgery in an outpatient clinic, the wound was healthy, not infected with normal bowel motion and no fever spikes, abdominal pain or abdominal distention.", + "fulltext_subclaims": [ + "The patient is a 1-year 9-month-old female.", + "The patient was referred for further investigations regarding the diagnosis of an intraabdominal mass versus an abdominal abscess.", + "The patient complained of abdominal pain and fever for 10 days.", + "The pain was located in the epigastric area radiating to the left upper quadrant.", + "The pain was associated with nausea, vomiting, and anorexia.", + "The pain was severe enough to awaken the patient from sleep.", + "The fever was intermittent with a maximum recorded value of 39 °C orally.", + "The fever responded well to paracetamol.", + "Physical examination revealed epigastric tenderness and left upper quadrant guarding to palpation.", + "The suspected mass could not be palpated.", + "Ultrasonography revealed a well-defined, multiloculated, cystic lesion in the epigastric region extending into the left upper quadrant.", + "The lesion showed foci of calcification with posterior acoustic enhancement.", + "The largest locule measured 4.8 × 4.0 × 5.6 cm.", + "The lesion contained swirling debris.", + "Findings highly suggest an organized abscess secondary to infected mesenteric cyst or a lymphangioma.", + "CT imaging revealed a multiloculated thick enhancing-walled fluid collection in the mesentery.", + "The largest locule measured 6.7 × 6.2 cm.", + "The lesion contained two tiny foci of calcifications.", + "The lesion caused a mass effect displacing adjacent bowel loops.", + "The lesion was associated with sub-centimetric enhancing locoregional lymph nodes.", + "A mild amount of fluid was seen in the pelvis.", + "CT findings suggest an organized abscess secondary to infected mesenteric cyst or a lymphangioma.", + "True-cut biopsies were not informative.", + "Histopathological examination of the biopsies indicated fragments of fibrinoid material with no viable cells.", + "The biopsies were composed of skeletal muscles and fibrous tissue.", + "A multidisciplinary team decision was made to excise the mass.", + "Intraoperative findings included multiloculated fused cystic lesions on the descending mesocolon.", + "The mass measured 8.0 × 5.0 × 4.0 cm.", + "Complete excision of the mass was performed.", + "Histopathological examination revealed thin-walled vascular spaces containing pale pink fluid.", + "The spaces were surrounded by loose fibrous tissue with inflammatory cellular infiltrate.", + "The spaces were lined by endothelial cells highlighted by CD31 and CD34 staining.", + "No evidence of malignancy was observed.", + "The patient received vancomycin, piperacillin/tazobactam, diclofenac, and paracetamol postoperatively.", + "Medications were stopped at day 5 postoperatively.", + "The NG tube was removed at day 3 postoperatively.", + "The patient passed flatus on day 2 postoperatively.", + "The patient passed stool at day 4 postoperatively.", + "The patient was discharged after 5 days postoperatively.", + "One week post-surgery, the wound was healthy and not infected.", + "The patient had normal bowel motion and no fever spikes at the 1-week follow-up." + ], + "summary": "We present a case of abdominal mesenteric cystic lymphangioma in a 1-year 9-month-old female patient, who complained of fever and abdominal pain for 10 days duration. Laboratory investigations, abdominal X-ray, ultrasonography, computed tomography and histopathological examination were all used to establish the diagnosis.", + "summary_subclaims": [ + "The patient is a 1-year 9-month-old female.", + "The patient complained of fever.", + "The patient complained of abdominal pain.", + "The symptoms lasted for 10 days.", + "Laboratory investigations were used to establish the diagnosis.", + "Abdominal X-ray was used to establish the diagnosis.", + "Ultrasonography was used to establish the diagnosis.", + "Computed tomography was used to establish the diagnosis.", + "Histopathological examination was used to establish the diagnosis." + ] + }, + { + "id": "multiclinsum_test_2653_en.txt", + "fulltext": "A 42-year-old Indonesian female, presented at Hamad General Hospital in Doha, Qatar complaining of an on and off lower abdominal pain mainly in the right iliac fossa. She had a normal delivery 15 years ago, had regular menstrual cycles, and no previous medical illnesses.\nShe was vitally stable, with no significant lymphadenopathy or pedal edema. Abdominal examination revealed midline palpable firm mass with mild tenderness. The mass arose from the pelvis, extending 2 cm below the umbilicus. There was no ascites. Complete blood picture, renal and liver function tests were normal except for hemoglobin of 11.7 g/dl, and CA 125 was elevated (251 KU/L).\nAbdominal ultrasound showed a large solid cystic mass in the right adnexa region, reaching the midline (≈6 × 13 cm) with mild vascularity in the solid component. Both ovaries were not separately visualized. There was mild left hydrosalpinx and mild ascites. Transvaginal ultrasound did not show the left ovary, but the right ovary was visualized separately (2.5 × 2.1 cm) and confirmed the presence of complex solid cystic mass in the middle of the pelvis. The mass (13.5 × 9.8 cm) extended to the left adnexa, with cystic area (9.2 × 5.9 cm) and a solid component (9.1 × 7 cm) that had increased vascularity. Further chest/abdomen/pelvis CT and MRI confirmed the size and solid/ cystic nature of the mass and showed no metastatic lesions, and also deviation of uterus to the left side.\nThe patient’s clinical picture was discussed at our gynecologic multidisciplinary meeting and total abdominal hysterectomy (TAH), bilateral salpingo-oopherectomy (BSO) and lymphadenectomy were decided. Patient underwent TAH + BSO plus infracolic omentectomy. During surgery, a freely mobile left ovarian mass was found with irregular surface and intact capsule. Right adnexa and uterus were normal. Patient had a smooth post-operative recovery and was discharged. Microscopic examination revealed an 11.0 cm left ovarian papillary thyroid carcinoma arising in SO , with metastatic papillary thyroid carcinoma to the right ovary. No malignancy was found in right fallopian tube, uterus or cervix and there were negative lymph nodes. Following the histopathology results, patient had thyroid function tests (TSH, free T4, thyroglobulin) that were all normal. Thyroid ultrasound revealed 7 × 11 mm complex nodule, a 6 × 6 mm complex nodule and a 3 × 4 mm cyst in the left thyroid lobe. No lesions were observed in the right thyroid lobe. The patient’s clinical findings were discussed at our thyroid multidisciplinary meeting where total thyroidectomy and radioactive iodine therapy were decided; however the patient refused further surgical management, and was lost to follow up as she left the country.\nUpon histopathologic examination, a papillary thyroid carcinoma was identified arising in SO tumor (11.0 cm in greatest dimension) of the left ovary , and a small metastatic focus measuring 0.1 cm in the right ovary. There was no malignancy in right fallopian tube, uterus or cervix and negative lymph nodes. Thyroglobulin immunohistochemical stained section highlighted the thyroid tissue in a background of ovarian tissue with SO, and confirmed the origin from thyroid tissue . AJCC Pathologic tumor staging was p T1b and FIGO stage was IB.", + "fulltext_subclaims": [ + "The patient is a 42-year-old Indonesian female.", + "She presented at Hamad General Hospital in Doha, Qatar.", + "She complained of on and off lower abdominal pain mainly in the right iliac fossa.", + "She had a normal delivery 15 years ago.", + "She had regular menstrual cycles.", + "She had no previous medical illnesses.", + "She was vitally stable.", + "There was no significant lymphadenopathy.", + "There was no pedal edema.", + "Abdominal examination revealed a midline palpable firm mass with mild tenderness.", + "The mass arose from the pelvis.", + "The mass extended 2 cm below the umbilicus.", + "There was no ascites.", + "Complete blood picture, renal and liver function tests were normal.", + "Hemoglobin was 11.7 g/dl.", + "CA 125 was elevated to 251 KU/L.", + "Abdominal ultrasound showed a large solid cystic mass in the right adnexa region.", + "The mass reached the midline and measured approximately 6 × 13 cm.", + "The mass had mild vascularity in the solid component.", + "Both ovaries were not separately visualized.", + "There was mild left hydrosalpinx.", + "There was mild ascites.", + "Transvaginal ultrasound did not show the left ovary.", + "The right ovary was visualized separately and measured 2.5 × 2.1 cm.", + "The mass measured 13.5 × 9.8 cm.", + "The mass extended to the left adnexa.", + "The cystic area measured 9.2 × 5.9 cm.", + "The solid component measured 9.1 × 7 cm.", + "The solid component had increased vascularity.", + "Chest/abdomen/pelvis CT and MRI confirmed the size and solid/cystic nature of the mass.", + "Chest/abdomen/pelvis CT and MRI showed no metastatic lesions.", + "The uterus was deviated to the left side.", + "The patient’s clinical picture was discussed at a gynecologic multidisciplinary meeting.", + "Total abdominal hysterectomy (TAH), bilateral salpingo-oopherectomy (BSO), and lymphadenectomy were decided.", + "The patient underwent TAH + BSO plus infracolic omentectomy.", + "During surgery, a freely mobile left ovarian mass was found.", + "The left ovarian mass had an irregular surface.", + "The left ovarian mass had an intact capsule.", + "The right adnexa and uterus were normal.", + "The patient had a smooth post-operative recovery.", + "The patient was discharged.", + "Microscopic examination revealed an 11.0 cm left ovarian papillary thyroid carcinoma arising in SO.", + "There was a metastatic papillary thyroid carcinoma to the right ovary.", + "No malignancy was found in the right fallopian tube, uterus, or cervix.", + "There were negative lymph nodes.", + "Thyroid function tests (TSH, free T4, thyroglobulin) were all normal.", + "Thyroid ultrasound revealed a 7 × 11 mm complex nodule in the left thyroid lobe.", + "Thyroid ultrasound revealed a 6 × 6 mm complex nodule in the left thyroid lobe.", + "Thyroid ultrasound revealed a 3 × 4 mm cyst in the left thyroid lobe.", + "No lesions were observed in the right thyroid lobe.", + "The patient’s clinical findings were discussed at a thyroid multidisciplinary meeting.", + "Total thyroidectomy and radioactive iodine therapy were decided.", + "The patient refused further surgical management.", + "The patient was lost to follow up as she left the country.", + "Histopathologic examination identified a papillary thyroid carcinoma arising in SO tumor of the left ovary.", + "The SO tumor measured 11.0 cm in greatest dimension.", + "There was a small metastatic focus measuring 0.1 cm in the right ovary.", + "There was no malignancy in the right fallopian tube, uterus, or cervix.", + "Lymph nodes were negative.", + "Thyroglobulin immunohistochemical staining highlighted thyroid tissue in a background of ovarian tissue with SO.", + "Thyroglobulin immunohistochemical staining confirmed the origin from thyroid tissue.", + "AJCC Pathologic tumor staging was p T1b.", + "FIGO stage was IB." + ], + "summary": "A 42-year old primiparous woman presented with abdominal pain and midline pelvic palpable firm mass arising from the pelvis. Imaging showed pelvic solid cystic mass. Total abdominal hysterectomy, bilateral salpingo-oopherectomy (TAH BSO) and infracolic omentectomy were performed. Histopathology revealed left ovary papillary thyroid carcinoma (PTC) arising in SO (11 cm) and metastatic papillary thyroid carcinoma in the right ovary. Thyroid functions tests were all normal, ultrasound thyroid showed two complex nodules in the left thyroid lobe. Total thyroidectomy was decided, but the patient refused further surgical management and was lost to follow up as she left the country. We undertook a comprehensive literature search, and MSO and thyroid management data from 23 additional publications were analyzed and tabulated. This PTC MSO is probably the largest reported in the literature.", + "summary_subclaims": [ + "A 42-year old primiparous woman presented with abdominal pain and midline pelvic palpable firm mass arising from the pelvis.", + "Imaging showed pelvic solid cystic mass.", + "Total abdominal hysterectomy, bilateral salpingo-oopherectomy (TAH BSO) and infracolic omentectomy were performed.", + "Histopathology revealed left ovary papillary thyroid carcinoma (PTC) arising in SO (11 cm).", + "Histopathology revealed metastatic papillary thyroid carcinoma in the right ovary.", + "Thyroid functions tests were all normal.", + "Ultrasound thyroid showed two complex nodules in the left thyroid lobe.", + "Total thyroidectomy was decided.", + "The patient refused further surgical management.", + "The patient was lost to follow up as she left the country.", + "We undertook a comprehensive literature search.", + "MSO and thyroid management data from 23 additional publications were analyzed and tabulated.", + "This PTC MSO is probably the largest reported in the literature." + ] + }, + { + "id": "multiclinsum_test_1376_en.txt", + "fulltext": "A 3-year-old boy was referred to our hospital with cough, edema, tachypnea, and tachycardia.\nOne week before admission, the patient began to exhibit a paroxysm of coughing with phlegm, accompanied with fatigue and plummeting level of physical activity. Soon afterwards, he exhibited edema all over the body, particularly on the face and both lower limbs. Half a day before admission, the patient developed tachypnea and tachycardia.\nIt is worth noting that the patient had a history of delayed physical growth development. He only learned to sit when he was 10 mo old, and he still could not crawl or stand at 1 year of age. He was sent to a hospital and diagnosed with growth retardation. Doctors guided the boy in a rehabilitation training program for 1 year, after which he appeared to walk and run with no significant difference compared with his peers. However, the parents found that his muscle tension was low, and that he fell over easily. In addition, the patient had strephenopodia after birth, which improved after the use of orthotics.\nThe family history was unremarkable.\nWhen the patient was admitted to our hospital, he had symmetrical edema in the face and lower extremities. The pulmonary respiratory sounds were rough with a few coarse rales. There was no protuberance in the precordial region. The apical impulse of the heart was diffused. Heart amplification was identified, and the apical beat was at the sixth intercostal space, 4.5 cm outside the middle line of the left clavicle. Neither thrill nor pericardium friction was found. The heart rhythm was regular with a gallop rhythm and low cardiac sound. The abdomen was supple with the liver 4 cm below the costal margin and 6 cm below the xiphoid, with the spleen impalpable. Moreover, the boy had an elongated face, inhibited facial expressions, a high palate arch , clawfoot, normal muscular strength, decreased muscular tone, and decreased bilateral knee reflexes. The Gower’s sign was positive, and the meningeal irritation sign was negative.\nThe serum cardiac troponin I level was 0.211 µg/L (normal < 0.034 µg/L). The level of brain natriuretic peptide reached up to 27500 pg/mL (normal < 215 pg/mL). The alanine aminotransferase level was 458 U/L (normal < 72 U/L), and aspartate aminotransferase level was 671 U/L (normal < 59 U/L). However, there was no significant increase in creatine kinase (99 U/L; normal < 170 U/L), creatine kinase myocardial band (2.29 μg/L; normal < 3.38 μg/L), and myoglobin (133.1 μg/L; normal < 121 μg/L).\nAfter one week in the hospital, Holter showed about 16.6% of ventricular premature beats (VPBs) of the total number of beats . Echocardiogram showed that the patient had enlarged, weakened left and right ventricles with decreased systolic function. The heart chamber sizes were as follows: Left atrium, 27 mm (normal < 18 mm); left ventricle, 58 mm (normal < 31 mm); right atrium, 40 mm (normal < 32 mm); right ventricle, 22 mm (normal < 11 mm). The ejection fraction was 18%, and the fraction of shortening was 8%. The systolic excursion of the tricuspid annular plane was 13 mm . Cardiac magnetic resonance imaging showed enlarged ventricles, reduced systolic function, and focal delayed enhancement .", + "fulltext_subclaims": [ + "A 3-year-old boy was referred to our hospital with cough, edema, tachypnea, and tachycardia.", + "One week before admission, the patient began to exhibit a paroxysm of coughing with phlegm.", + "The patient exhibited fatigue and plummeting level of physical activity.", + "The patient exhibited edema all over the body, particularly on the face and both lower limbs.", + "Half a day before admission, the patient developed tachypnea and tachycardia.", + "The patient had a history of delayed physical growth development.", + "He only learned to sit when he was 10 mo old.", + "He still could not crawl or stand at 1 year of age.", + "He was diagnosed with growth retardation.", + "Doctors guided the boy in a rehabilitation training program for 1 year.", + "After rehabilitation, he appeared to walk and run with no significant difference compared with his peers.", + "The parents found that his muscle tension was low.", + "The parents found that he fell over easily.", + "The patient had strephenopodia after birth.", + "Strephenopodia improved after the use of orthotics.", + "The family history was unremarkable.", + "On admission, the patient had symmetrical edema in the face and lower extremities.", + "The pulmonary respiratory sounds were rough with a few coarse rales.", + "The apical impulse of the heart was diffused.", + "Heart amplification was identified.", + "The apical beat was at the sixth intercostal space, 4.5 cm outside the middle line of the left clavicle.", + "The heart rhythm was regular with a gallop rhythm and low cardiac sound.", + "The liver was 4 cm below the costal margin and 6 cm below the xiphoid.", + "The boy had an elongated face.", + "The boy had inhibited facial expressions.", + "The boy had a high palate arch.", + "The boy had clawfoot.", + "The boy had normal muscular strength.", + "The boy had decreased muscular tone.", + "The boy had decreased bilateral knee reflexes.", + "The Gower’s sign was positive.", + "The meningeal irritation sign was negative.", + "The serum cardiac troponin I level was 0.211 µg/L.", + "The level of brain natriuretic peptide was 27500 pg/mL.", + "The alanine aminotransferase level was 458 U/L.", + "The aspartate aminotransferase level was 671 U/L.", + "The creatine kinase level was 99 U/L.", + "The creatine kinase myocardial band level was 2.29 μg/L.", + "The myoglobin level was 133.1 μg/L.", + "After one week in the hospital, Holter showed about 16.6% of ventricular premature beats of the total number of beats.", + "Echocardiogram showed that the patient had enlarged, weakened left and right ventricles with decreased systolic function.", + "The left atrium was 27 mm.", + "The left ventricle was 58 mm.", + "The right atrium was 40 mm.", + "The right ventricle was 22 mm.", + "The ejection fraction was 18%.", + "The fraction of shortening was 8%.", + "The systolic excursion of the tricuspid annular plane was 13 mm.", + "Cardiac magnetic resonance imaging showed enlarged ventricles.", + "Cardiac magnetic resonance imaging showed reduced systolic function.", + "Cardiac magnetic resonance imaging showed focal delayed enhancement." + ], + "summary": "A 3-year-old pre-school boy was admitted to our hospital with cough, edema, tachypnea, and an increased heart rate. The patient was clinically diagnosed with severe dilated cardiomyopathy and heart failure, and subsequent gene examination confirmed the diagnosis of NM with a mutation in MYPN. Captopril, diuretics, low-dose digoxin, and dobutamine were administered. After 22 d of hospitalization, the patient was discharged due to the improvement of clinical symptoms. During the follow-up period, the patient died of refractory heart failure.", + "summary_subclaims": [ + "A 3-year-old pre-school boy was admitted to our hospital with cough, edema, tachypnea, and an increased heart rate.", + "The patient was clinically diagnosed with severe dilated cardiomyopathy and heart failure.", + "Subsequent gene examination confirmed the diagnosis of NM with a mutation in MYPN.", + "Captopril, diuretics, low-dose digoxin, and dobutamine were administered.", + "After 22 d of hospitalization, the patient was discharged due to the improvement of clinical symptoms.", + "During the follow-up period, the patient died of refractory heart failure." + ] + }, + { + "id": "multiclinsum_test_666_en.txt", + "fulltext": "On December 2016, a 55-year-old, non-smoker Chinese male with an ECOG score of 0 underwent chest X-ray due to fracture of the left clavicle. The chest X-ray incidentally revealed a space-occupying lesion in the left lower lobe of the lung. Except for persistent coughing for a month and mild hemoptysis, no other clinical symptoms were reported by the patient. Thoracic computed tomography (CT) scans confirmed the chest X-ray results showing a tumor volume of 41x44mm with a relatively clear margin. The disease was pathologically staged as T2aN0M0 (stage IB) after left lower lobectomy and mediastinoscopy. Further histologic examination of the surgical tissues revealed adenosquamous lung carcinoma with predominantly papillary adenocarcinoma pattern (Additional file : Figure S1). Adjuvant chemotherapy was also administered to the patient with a total of 4 cycles of chemotherapy regimen including 2 cycles of 40 mg vinorelbine plus 80 mg nedaplatin and 2 cycles of 100 mg docetaxel plus 80 mg nedaplatin administered every 3 weeks. On August 2017, chest CT revealed no disease recurrence in the lungs ; however, colonic polyps were discovered during his physical examination. Initial biopsy revealed tubulovillous adenoma with low-grade intraepithelial neoplasia. Complete endoscopic resection was scheduled and removed three polyps in the transverse colon with sizes between 6 to 8 mm. Histopathologic analyses revealed moderately differentiated adenocarcinoma with submucosal invasion. No systemic therapy was administered to the patient. On December 2017, after being disease-free for about 5.4 months, the patient returned to the clinic due to pain and discomfort in the right waist. Ultrasonography and CT urography revealed moderately increased renal echogenicity and a 51x60x68mm obstruction in the right kidney, respectively, which are highly suggestive of renal carcinoma . In addition to revealing an elevated 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) uptake of the right kidney that is indistinguishable from the liver, positron-emission tomography (PET)/CT scanning also revealed mediastinal lymphadenopathy and slightly elevated FDG uptake of the sigmoid colon, suggestive of malignancy and metastasis . No sign of disease recurrence or relapse was detected in the thoracic region . Right radical nephrectomy and inferior vena cava thrombectomy were performed to remove the 55x53x35mm tumor. Further examination revealed renal pelvis invasion with renal vein involvement and presence of a 13 mm nodule in the renal hilum. No growth was found in the renal capsule and ureteral muscle. Histopathology results revealed poorly differentiated tumor cells. The new malignancy was suspected to be squamous cell urothelial carcinoma, but with the possibility of kidney metastasis considering a history of lung cancer. However, the lack of immunoreactivity of the kidney tumor sample with thyroid transcription factor 1 (TTF-1) and cytokeratin 7 (CK-7) antibodies did not support pulmonary origin . To rule out the possibility of the tumor in the kidney being another primary site, we explored the use of capture-based targeted NGS to understand its biology compared to the two earlier malignancies. The three archived surgical tissues, as well as paired white blood cell samples, were sequenced using a targeted panel with 520 cancer-related genes, spanning 1.64 Mb of the human genome (OncoScreen Plus, Burning Rock Biotech). A total of 16, 15 and 7 mutations were detected in the lung, kidney and colon tumor samples, respectively . Interestingly, comparative analysis revealed a similar mutational signature between the lung and kidney tumors, sharing 67% (10/15) of the mutations. Except for the FANCC W113X and KMT2C S321 N common to the three tumor samples, no other mutations were shared between the colon and either the lung or the kidney tumor samples . These sequencing results indicate that both the lung and colon tumors were primary tumors; while the kidney tumor originated from the lung . Consistent with the detection of FANCC W113X in all the three tumors, the pathogenic mutation was also detected in his germline as a heterozygous mutation . In addition, FANCC W113X was also detected in the son of the patient (III, Fig. ). Further investigation of the family history revealed that the father of the patient was previously treated for colon cancer with no recurrence reported (I, Fig. 3). After the nephrectomy, the patient did not receive further systemic treatment due to persistent fever and infection. The patient passed away on August 2018 due to severe infection, with an overall survival of 20.4 months. His son is still currently cancer-free.", + "fulltext_subclaims": [ + "The patient is a 55-year-old, non-smoker Chinese male.", + "The patient underwent chest X-ray due to fracture of the left clavicle.", + "The chest X-ray incidentally revealed a space-occupying lesion in the left lower lobe of the lung.", + "The patient reported persistent coughing for a month.", + "The patient reported mild hemoptysis.", + "Thoracic computed tomography (CT) scans confirmed the chest X-ray results.", + "The tumor volume was 41x44mm with a relatively clear margin.", + "The disease was pathologically staged as T2aN0M0 (stage IB).", + "The disease was staged after left lower lobectomy and mediastinoscopy.", + "Histologic examination revealed adenosquamous lung carcinoma.", + "The adenosquamous lung carcinoma had a predominantly papillary adenocarcinoma pattern.", + "Adjuvant chemotherapy was administered with a total of 4 cycles.", + "The chemotherapy regimen included 2 cycles of 40 mg vinorelbine plus 80 mg nedaplatin.", + "The chemotherapy regimen included 2 cycles of 100 mg docetaxel plus 80 mg nedaplatin.", + "The chemotherapy was administered every 3 weeks.", + "On August 2017, chest CT revealed no disease recurrence in the lungs.", + "Colonic polyps were discovered during the physical examination.", + "Initial biopsy revealed tubulovillous adenoma with low-grade intraepithelial neoplasia.", + "Complete endoscopic resection was scheduled.", + "Three polyps were removed in the transverse colon.", + "The sizes of the polyps were between 6 to 8 mm.", + "Histopathologic analyses revealed moderately differentiated adenocarcinoma with submucosal invasion.", + "No systemic therapy was administered.", + "On December 2017, the patient returned to the clinic due to pain and discomfort in the right waist.", + "Ultrasonography revealed moderately increased renal echogenicity.", + "CT urography revealed a 51x60x68mm obstruction in the right kidney.", + "The obstruction was highly suggestive of renal carcinoma.", + "PET/CT scanning revealed mediastinal lymphadenopathy.", + "PET/CT scanning revealed slightly elevated FDG uptake of the sigmoid colon.", + "The elevated FDG uptake was suggestive of malignancy and metastasis.", + "No sign of disease recurrence or relapse was detected in the thoracic region.", + "Right radical nephrectomy and inferior vena cava thrombectomy were performed.", + "The tumor removed was 55x53x35mm.", + "Further examination revealed renal pelvis invasion with renal vein involvement.", + "A 13 mm nodule was found in the renal hilum.", + "No growth was found in the renal capsule and ureteral muscle.", + "Histopathology results revealed poorly differentiated tumor cells.", + "The new malignancy was suspected to be squamous cell urothelial carcinoma.", + "The possibility of kidney metastasis was considered.", + "The lack of immunoreactivity with TTF-1 and CK-7 antibodies did not support pulmonary origin.", + "Capture-based targeted NGS was explored to understand the tumor biology.", + "Three archived surgical tissues and paired white blood cell samples were sequenced.", + "A targeted panel with 520 cancer-related genes was used.", + "A total of 16 mutations were detected in the lung tumor sample.", + "A total of 15 mutations were detected in the kidney tumor sample.", + "A total of 7 mutations were detected in the colon tumor sample.", + "Comparative analysis revealed a similar mutational signature between the lung and kidney tumors.", + "The lung and kidney tumors shared 67% (10/15) of the mutations.", + "FANCC W113X and KMT2C S321 N were common to the three tumor samples.", + "No other mutations were shared between the colon and either the lung or the kidney tumor samples.", + "Sequencing results indicated that both the lung and colon tumors were primary tumors.", + "The kidney tumor originated from the lung.", + "FANCC W113X was detected in all three tumors.", + "FANCC W113X was also detected in the patient's germline as a heterozygous mutation.", + "FANCC W113X was also detected in the patient's son.", + "The father of the patient was previously treated for colon cancer.", + "The father of the patient had no recurrence reported.", + "The patient did not receive further systemic treatment after the nephrectomy.", + "The patient passed away on August 2018 due to severe infection.", + "The patient's overall survival was 20.4 months.", + "The patient's son is still currently cancer-free." + ], + "summary": "In December 2016, a 55-year-old Chinese male was diagnosed with stage IB lung adenosquamous carcinoma and treated with left lower lobectomy and 4 cycles of platinum-based chemotherapy. After being disease-free for 3.5 months, three colonic polyps were discovered and were diagnosed as invasive adenocarcinoma after polypectomy. Within 5.4 months from the polypectomy, squamous cell renal carcinoma was identified and was managed by radical nephrectomy. Immunohistochemistry results were inconclusive on the origin of the kidney tumor. Hence, the three archived surgical tissue samples were sequenced using a targeted panel with 520 cancer-related genes. Analysis revealed similar mutational signature between the lung and kidney tumors and a distinct mutational profile for the colon tumor, suggesting that the lung and colon malignancies were primary tumors, while the kidney tumor originated from the lung, revealing a diagnosis of metastatic double primary cancer - lung carcinoma with renal cell metastasis and second primary colon carcinoma.", + "summary_subclaims": [ + "A 55-year-old Chinese male was diagnosed with stage IB lung adenosquamous carcinoma in December 2016.", + "He was treated with left lower lobectomy and 4 cycles of platinum-based chemotherapy.", + "After being disease-free for 3.5 months, three colonic polyps were discovered.", + "The colonic polyps were diagnosed as invasive adenocarcinoma after polypectomy.", + "Within 5.4 months from the polypectomy, squamous cell renal carcinoma was identified.", + "The kidney tumor was managed by radical nephrectomy.", + "Immunohistochemistry results were inconclusive on the origin of the kidney tumor.", + "The three archived surgical tissue samples were sequenced using a targeted panel with 520 cancer-related genes.", + "Analysis revealed a similar mutational signature between the lung and kidney tumors.", + "Analysis revealed a distinct mutational profile for the colon tumor.", + "The analysis suggested that the lung and colon malignancies were primary tumors.", + "The analysis suggested that the kidney tumor originated from the lung.", + "The diagnosis was metastatic double primary cancer - lung carcinoma with renal cell metastasis and second primary colon carcinoma." + ] + }, + { + "id": "multiclinsum_test_2561_en.txt", + "fulltext": "In our detailed case presentation of the 4-year-old female patient with FLH, we observed and documented specific clinical signs and symptoms that warranted our attention. Upon examination, the patient exhibited pronounced enlargement of the index finger and thumb of the right hand, a hallmark sign of macrodactyly associated with FLH. This enlargement was not uniform; the thumb and index finger were disproportionately larger compared to the other fingers, with noticeable swelling and a firm texture upon palpation, indicating the presence of fibroadipose tissue.\nThe patient reported pain, which was more pronounced at night, and a tingling sensation along with occasional episodes of bluish discoloration of the affected fingers, suggesting compromised vascular supply or nerve compression. These symptoms were particularly evident in the anatomical areas surrounding the median nerve's path through the wrist and hand, which is commonly affected in FLH. The anatomical distribution of symptoms, coupled with the physical manifestations in specific fingers, provided crucial insights into the condition's localized impact on the hand's structure and function.\nOn examination the first and second fingers of the right hand appear larger than the adjacent fingers, with finger 2 measuring 6 × 1.9 cm and finger 1 measuring 6 × 2 cm. Angulation is present measured at 20 degree, directed towards the ulnar side on the distal dan middle phalanx There is discontinuity observed, no tenderness, the sensation is detectable at the base, middle, and tip of the second finger, as well as at the base and tip of the first finger. Range of motion within normal limits, grasping ability present. Sensory within normal limits, comparable to the surrounding and contralateral side. Comparison with patient's mother, size of the patient's mother first finger is 4 × 1,5 cm, and the second finger is 5 × 1,5 cm . Radiographs indicated widespread edema and heightened soft tissue density in the 1st and 2nd finger of the right hand, specifically on the palm side.\nBefore surgery, we performed the pre-operation examination a week after first admission, the condition is still the same as when it was first examined . We did a radiologic examination to examine the size of the bone . In addition to the initial X-ray imaging, further diagnostic evaluations were carried out to confirm the diagnosis of FLH with Macrodactyly and assess its extent. The X-ray images of the patient's right hand revealed an increase in soft tissue density around the affected fingers, indicative of fibroadipose tissue proliferation. Furthermore, the images showed enlargement of the phalanges in the index finger and thumb, consistent with macrodactyly. These findings align with the characteristic radiological features of FLH, including the disproportionate growth of soft tissues and bones in the affected digits. While Magnetic Resonance Imaging (MRI) is recognized as a superior diagnostic tool for assessing soft tissue lesions and was indeed planned for a comprehensive evaluation of the fibrolipomatous hamartoma, the availability of MRI was significantly limited due to long waiting lists. This constraint necessitated prioritizing immediate clinical assessment and intervention based on available diagnostic resources, such as X-ray imaging, which provided initial insights into the condition's impact on bone and soft tissue.\nA month after clinical assessment, the surgical intervention for the patient was meticulously planned and executed with the aim of addressing the significant enlargement of the right second finger, while ensuring the preservation of hand function and minimizing potential complications. The procedure comprised several key steps. Debulking: During the surgical debulking of the patient's right hand, specifically targeting the enlarged second finger affected by FLH, careful attention was paid to the composition and location of the tissue being excised. The procedure focused on removing excessive fibroadipose tissue that had proliferated around the median nerve and within the soft tissue matrix of the finger, characteristic of FLH. The excised mass predominantly consisted of a mixture of soft fibrous and adipose tissues. These components are typical of FLH, where fibrous tissue represents the proliferative fibroblasts and collagen deposition around the nerve sheath, and adipose tissue indicates the abnormal fat accumulation within and around the nerve bundles. Notably, the tissue exhibited a soft, pliable consistency, with areas of harder fibrous nodules interspersed within the fatty matrix, reflecting the heterogenous nature of FLH lesions. No significant portions of hard tissue, such as bone, were involved in the debulking process, as FLH primarily affects the soft tissue surrounding the nerve structures. The surgical removal was carefully executed to avoid damage to the nerve itself, ensuring that only the overgrown fibroadipose tissue contributing to the patient's symptoms and functional impairment was excised. This surgical debulking aimed to alleviate the mechanical pressure on the nerve, reduce the bulk of the finger to improve its function and appearance, and, importantly, to obtain tissue for histopathological examination, although, as previously noted, histological analysis was not pursued in this case.\nWedge Osteotomy of the Middle Phalanx: To correct the angulation and disproportionate enlargement of the second finger, a wedge osteotomy was performed on the middle phalanx. This involved making precise, angular cuts in the bone to remove a wedge-shaped segment, allowing for the realignment of the finger. The osteotomy was carefully planned based on pre-operative imaging to ensure the correction of angulation while maintaining the finger's length and functionality. K-Wire Insertion: Following the osteotomy, stabilization was achieved by inserting a Kirschner wire (K-Wire) into the middle phalanx. The K-Wire was used to secure the bone in its newly aligned position, ensuring proper healing and consolidation of the osteotomy site. The wire was inserted in a manner that allowed for optimal bone positioning while minimizing interference with finger movement. . Intraoperative mass was found at palmar region with a suspicion of fibro lipoma, it was decided that the mass was not resected. The patient was scheduled for MRI examination for further work up. , shows the clinical appearance after the surgery.\nAfter the surgical intervention, which included debulking, wedge osteotomy, and K-Wire insertion, the patient underwent a structured post-operative follow-up schedule designed to monitor healing, evaluate the functional recovery of the affected fingers, and mitigate potential complications. The first follow-up, conducted two weeks post-surgery, focused on wound care and the assessment of any immediate post-operative complications. Subsequent follow-ups were scheduled monthly for the first six months, during which the progress of finger function recovery and the effectiveness of the surgical intervention were closely monitored.\nThe decision to perform surgical intervention on the second finger as a priority was informed by its considerable enlargement, which was more pronounced than other affected areas. This enlargement of the second finger had a significant impact on the patient's hand function, manifesting as impaired gripping ability and dexterity. Addressing the second finger first aimed to alleviate the most immediate functional limitations and discomfort experienced by the patient, with a view to improving quality of life and hand usability in daily activities.\nA comprehensive rehabilitation program was initiated early in the post-operative period to enhance the patient's hand functionality and alleviate stiffness. This program, tailored to the patient's specific needs, included physical therapy sessions emphasizing range of motion exercises, strengthening exercises for the hand and fingers, and sensory re-education activities. The patient was also provided with home exercise routines to encourage continuous improvement outside of therapy sessions. Special attention was given to incorporating play-based therapy techniques suitable for the patient's age to maintain engagement and compliance with the rehabilitation process.\nThroughout the rehabilitation phase, the patient demonstrated a gradual improvement in grip strength, finger mobility, and a decrease in the stiffness of the right hand. These improvements were significant milestones in the patient's recovery, contributing to an enhanced ability to perform daily activities and an improved quality of life. The patient continues to be monitored regularly to assess long-term outcomes and the potential need for additional interventions.", + "fulltext_subclaims": [ + "The patient is a 4-year-old female.", + "The patient has fibrolipomatous hamartoma (FLH).", + "The patient exhibited enlargement of the index finger and thumb of the right hand.", + "The enlargement was not uniform.", + "The thumb and index finger were disproportionately larger compared to the other fingers.", + "There was noticeable swelling and a firm texture upon palpation.", + "The patient reported pain, more pronounced at night.", + "The patient reported a tingling sensation.", + "The patient had occasional episodes of bluish discoloration of the affected fingers.", + "The symptoms were evident in the anatomical areas surrounding the median nerve's path.", + "The first and second fingers of the right hand appear larger than the adjacent fingers.", + "Finger 2 measured 6 × 1.9 cm.", + "Finger 1 measured 6 × 2 cm.", + "Angulation was present, measured at 20 degrees.", + "The angulation was directed towards the ulnar side on the distal and middle phalanx.", + "There was discontinuity observed.", + "There was no tenderness.", + "Sensation was detectable at the base, middle, and tip of the second finger.", + "Sensation was detectable at the base and tip of the first finger.", + "Range of motion was within normal limits.", + "Grasping ability was present.", + "Sensory was within normal limits.", + "Radiographs indicated widespread edema in the 1st and 2nd finger of the right hand.", + "Radiographs showed heightened soft tissue density in the 1st and 2nd finger of the right hand.", + "The increased soft tissue density was on the palm side.", + "The pre-operation examination was performed a week after first admission.", + "The condition was still the same as when it was first examined.", + "An X-ray imaging was performed.", + "X-ray images showed an increase in soft tissue density around the affected fingers.", + "The images showed enlargement of the phalanges in the index finger and thumb.", + "The surgical intervention was planned to address the significant enlargement of the right second finger.", + "The surgical debulking targeted the enlarged second finger.", + "The excised mass consisted of a mixture of soft fibrous and adipose tissues.", + "The tissue exhibited a soft, pliable consistency.", + "The tissue had areas of harder fibrous nodules interspersed within the fatty matrix.", + "No significant portions of hard tissue, such as bone, were involved in the debulking process.", + "A wedge osteotomy was performed on the middle phalanx.", + "Stabilization was achieved by inserting a Kirschner wire (K-Wire).", + "An intraoperative mass was found at the palmar region.", + "The mass was suspected to be a fibro lipoma.", + "The mass was not resected.", + "The patient was scheduled for an MRI examination.", + "The first follow-up was conducted two weeks post-surgery.", + "Subsequent follow-ups were scheduled monthly for the first six months.", + "The decision to perform surgical intervention on the second finger was informed by its considerable enlargement.", + "The enlargement of the second finger had a significant impact on the patient's hand function.", + "A comprehensive rehabilitation program was initiated.", + "The rehabilitation program included physical therapy sessions.", + "The patient demonstrated a gradual improvement in grip strength.", + "The patient demonstrated a gradual improvement in finger mobility.", + "There was a decrease in the stiffness of the right hand." + ], + "summary": "A-4 years old girl presents with the index finger and thumb larger than the surrounding fingers and has been present since birth. Over time, the index finger and thumb continue to enlarge. This enlargement is accompanied by pain, a tingling sensation, and occasional bluish discoloration, especially at night. The patient is the third child out of four siblings, with a history of normal birth and no abnormalities in other parts of the body. The patient can grip objects in daily activities, but there is noticeable stiffness in the right hand.", + "summary_subclaims": [ + "A-4 years old girl presents with the index finger and thumb larger than the surrounding fingers and has been present since birth.", + "The index finger and thumb continue to enlarge.", + "The enlargement is accompanied by pain.", + "The enlargement is accompanied by a tingling sensation.", + "The enlargement is accompanied by occasional bluish discoloration, especially at night.", + "The patient is the third child out of four siblings.", + "The patient has a history of normal birth.", + "There are no abnormalities in other parts of the body.", + "The patient can grip objects in daily activities.", + "There is noticeable stiffness in the right hand." + ] + }, + { + "id": "multiclinsum_test_2966_en.txt", + "fulltext": "A 27-year-old married woman (gravida 0) was admitted to a local hospital with a history of 51 days of amenorrhea, lower abdominal pain and vaginal bleeding for 5 days. Her previous menstrual cycles were regular. Her medical history and family history were unremarkable. The general condition of the patient appeared to be good, and pelvic examination revealed a mass in the right adnexal area with tenderness. The urine test showed she was pregnant, and serum β-hCG level was more than 200,000 mIU/ml. Transvaginal ultrasound (TVS) revealed a right adnexal mass and profuse abdominal fluid accumulation.\nAccording to an initial diagnosis of ectopic pregnancy, laparoscopic exploration was performed. The right ovary was 5*6 cm, partially cystic, ruptured and surrounded by a hematoma. The left ovary and both fallopian tubes were intact. Approximately 500 ml of intraperitoneal blood was noted. The cystic mass of the right ovary was dissected and sent to pathological diagnosis. On the fifth postoperative day, serum β-hCG levels was 14,510 mIU/ml. The patient then transferred to our hospital six days after the surgery. The pathological consult confirmed a pure choriocarcinoma of the right ovary, and an immunohistochemical panel was performed and the samples analyzed were positive for Pan Cytokeratin (AE1/AE3), hCG, human placental lactogen (hPL) and Ki-67(60%), and negative for p53. .\nAt the 7th and 10th postoperative day, the serum β-hCG levels fell to 5907 and 2000 mIU/ml, respectively. Further imaging examination was proceeded ten days after the surgery. The contrast pelvic MRI showed the right ovary was 2.1*2.9*3.2 cm, at the front of which a mass of 1.2 cm*1.0 cm was observed. PET-CT showed bilateral ovarian nodules with hypermetabolism, physiological uptake considered, no other specific abnormalities were observed. Other related tests were examined: CA125 (cancer antigen 125): 70.81 U/ml, AFP (alpha fetoprotein): 2.28 ng/ml. As the endometrium thickness was only 5 mm, endometrial biopsy had not been performed.\nThe patient received five courses of EP-EMA chemotherapy, including cisplatin (80 mg/m2) and etoposide (100 mg/m2), D1; etoposide (100 mg/m2), methotrexate (100 mg/m2 iv and 200 mg/m2 ivgtt), and actinomycin-D (0.5 mg), D7–8, at two-week intervals. Goserelin (3.6 mg) was injected before the beginning of chemotherapy and at four-week intervals during the treatment to protect the ovarian function. During the chemotherapy, the patient was monitored weekly for serum levels of β-hCG, and a rapidly decrease was detected. We observed normalization of the CA125 serum level after one course of chemotherapy. The β-hCG level decreased to normal after two and a half courses of chemotherapy and remained normal thereafter. The contrast pelvic MRIs performed once a month during the chemotherapy showed reduced lesion which became undetectable during the fourth course. The patient remains without evidence of disease 32 months after chemotherapy, her menstruation recovered 12 months after chemotherapy, and gave birth to a healthy baby 25 months after chemotherapy.\nIndividual DNA polymorphic analysis was used to verify the presence or absence of paternal genetic material. DNA from paraffin-embedded tumor tissue was compared to the patients’ and her husband’s peripheral blood DNA. Manual microdissection of the tumor cells was performed to eliminate the contamination of maternal DNA. Following extraction of DNA from the formalin-fixed and paraffin wax embedded material (QIAamp DNA FFPE Tissue Kit, Qiagen, Valencia, CA, USA), and from blood samples (ZR Genomic DNA-Tissue MiniPrep Kit, Zymo Research, CA, USA) all samples were quantified by NanoDrop (Thermo Scientific, Wilmington, USA), and MicroreaderTM 21 ID system, MicroreaderTM 23sp ID system (Beijing Microread Genetics Co., Ltd., Beijing, China) were respectively used to amplify 10 ng DNA from each biopsy and blood samples. Amplified products were then detected using an ABI 3730xl Genetic Analyzer (Applied Biosystems, CA, USA). Electrophoresis results were analyzed using GeneMapper® ID v.3.2 (Applied Biosystems, CA, USA), and the genetic profiles of the biopsy and peripheral blood were compared.\nWe studied the genetic profiles of 43 highly polymorphic short tandem repeats (STRs) in DNA samples prepared from the patient, spouse and tumor. At 25/43 loci examined, the tumor specimen was shown to contain the paternal allele but not the maternal DNA (D21S11, D18S51, D6S1043, D3S1358, D7S820, D16S539, Penta D, D2S441, vWA, TPOX, TH01, FGA, D18S535, D19S253, D20S470, D22-GATA198B05, D16S539, D8S1132, D4S2366, D13S325, D9S925, D3S3045, D10S1435, D17S1290, D5S2500). At 18/43 loci examined, it could not be determined whether the tumor contained paternal allele because the patient and spouse shared one or two identical alleles (D19S433, D5S818, AMEL, D13S317, CSF1PO, D8S1179, Penta E, D12S391, D2S1338, D6S477, D15S659, D11S2368, D1S1656, D7S3048, D21S1270, D14S608, D12S391, D2S1338). Therefore, none of the loci could be proved to contain maternal allele only. At 20/43 loci examined, the tumor was triploid, which was in accord with the nuclear-heteromorphism of tumor cells. Twelve representative loci from these analyses were summarized in Table and Fig. . In more than half (25/43) of the loci studied we were able to demonstrate the presence of paternal DNA in the tumor, indicating a gestational origin for the tumor.", + "fulltext_subclaims": [ + "The patient was a 27-year-old married woman with 51 days of amenorrhea.", + "She had lower abdominal pain and vaginal bleeding for 5 days.", + "Her previous menstrual cycles were regular.", + "Her medical history and family history were unremarkable.", + "Pelvic examination revealed a mass in the right adnexal area with tenderness.", + "The urine test showed she was pregnant.", + "Serum β-hCG level was more than 200,000 mIU/ml.", + "Transvaginal ultrasound revealed a right adnexal mass and profuse abdominal fluid accumulation.", + "An initial diagnosis of ectopic pregnancy was made.", + "Laparoscopic exploration was performed.", + "The right ovary was 5*6 cm, partially cystic, ruptured, and surrounded by a hematoma.", + "The left ovary and both fallopian tubes were intact.", + "Approximately 500 ml of intraperitoneal blood was noted.", + "The cystic mass of the right ovary was dissected and sent to pathological diagnosis.", + "On the fifth postoperative day, serum β-hCG levels was 14,510 mIU/ml.", + "The patient transferred to our hospital six days after the surgery.", + "The pathological consult confirmed a pure choriocarcinoma of the right ovary.", + "An immunohistochemical panel was performed.", + "The samples were positive for Pan Cytokeratin (AE1/AE3), hCG, human placental lactogen (hPL), and Ki-67(60%).", + "The samples were negative for p53.", + "At the 7th postoperative day, the serum β-hCG level fell to 5907 mIU/ml.", + "At the 10th postoperative day, the serum β-hCG level fell to 2000 mIU/ml.", + "Contrast pelvic MRI showed the right ovary was 2.1*2.9*3.2 cm.", + "A mass of 1.2 cm*1.0 cm was observed at the front of the right ovary.", + "PET-CT showed bilateral ovarian nodules with hypermetabolism.", + "No other specific abnormalities were observed on PET-CT.", + "CA125 was 70.81 U/ml.", + "AFP was 2.28 ng/ml.", + "Endometrial biopsy had not been performed.", + "The patient received five courses of EP-EMA chemotherapy.", + "Goserelin was injected before the beginning of chemotherapy.", + "Goserelin was injected at four-week intervals during the treatment.", + "The β-hCG level decreased to normal after two and a half courses of chemotherapy.", + "The β-hCG level remained normal thereafter.", + "Contrast pelvic MRIs performed once a month showed reduced lesion.", + "The lesion became undetectable during the fourth course of chemotherapy.", + "The patient remains without evidence of disease 32 months after chemotherapy.", + "Her menstruation recovered 12 months after chemotherapy.", + "She gave birth to a healthy baby 25 months after chemotherapy.", + "Individual DNA polymorphic analysis was used to verify the presence or absence of paternal genetic material.", + "DNA from paraffin-embedded tumor tissue was compared to the patient’s and her husband’s peripheral blood DNA.", + "Manual microdissection of the tumor cells was performed to eliminate contamination of maternal DNA.", + "DNA was extracted from formalin-fixed and paraffin wax embedded material.", + "DNA was extracted from blood samples.", + "All samples were quantified by NanoDrop.", + "MicroreaderTM 21 ID system and MicroreaderTM 23sp ID system were used to amplify DNA.", + "Amplified products were detected using an ABI 3730xl Genetic Analyzer.", + "Electrophoresis results were analyzed using GeneMapper® ID v.3.2.", + "The genetic profiles of 43 highly polymorphic short tandem repeats (STRs) were studied.", + "At 25/43 loci, the tumor specimen contained the paternal allele but not the maternal DNA.", + "At 18/43 loci, it could not be determined whether the tumor contained paternal allele.", + "At 20/43 loci, the tumor was triploid.", + "In more than half (25/43) of the loci studied, the presence of paternal DNA in the tumor was demonstrated.", + "The presence of paternal DNA indicated a gestational origin for the tumor." + ], + "summary": "In the present case, a 27-year-old patient with a history of amenorrhea, lower abdominal pain and vaginal bleeding received a laparoscopic dissection of cystic mass of the right ovary according to an initial diagnosis of ectopic pregnancy. Primary choriocarcinoma of the ovary was diagnosed by pathology, but its origin was uncertain. DNA polymorphic analysis was then performed and a gestational origin was confirmed. The patient subsequently exhibited an excellent response to chemotherapy, achieved complete remission and gave birth to a healthy baby.", + "summary_subclaims": [ + "The patient is a 27-year-old woman.", + "The patient had a history of amenorrhea.", + "The patient had lower abdominal pain.", + "The patient had vaginal bleeding.", + "The initial diagnosis was ectopic pregnancy.", + "A laparoscopic dissection of a cystic mass of the right ovary was performed.", + "Primary choriocarcinoma of the ovary was diagnosed by pathology.", + "The origin of the choriocarcinoma was uncertain.", + "DNA polymorphic analysis was performed.", + "A gestational origin was confirmed.", + "The patient exhibited an excellent response to chemotherapy.", + "The patient achieved complete remission.", + "The patient gave birth to a healthy baby." + ] + }, + { + "id": "multiclinsum_test_2534_en.txt", + "fulltext": "A 49-year-old non-smoker female with known afibrinogenemia and antithrombin (AT) deficiency was admitted to the emergency room (ER) for acute substernal chest pain. She had a history of pyelonephritis, had received treatment for a multinodular goiter that had caused hypothyroidism, and also had congenital deafness. Her parents were consanguineous, and her father died from a surgically-induced pulmonary embolism. Her brother suffered from the same combined afibrinogenemia and AT deficiency. Her sister died from pulmonary embolism during her first pregnancy, at the age of 22, and had also suffered from AT deficiency yet with normal fibrinogen levels.\nAfibrinogenemia was diagnosed when the patient was 3 months old, following a trauma-induced intracranial hemorrhage. DNA sequencing, performed several years after the diagnosis, highlighted a homozygous (c.510 + 1G > T) substitution in the splicing site of the 4th intron of the fibrinogen alpha-chain. Routine coagulation test results revealed dramatically-prolonged activated partial thromboplastin time (aPTT) (>240 s) and a prothrombin time (PT) >120 s, with undetectable levels of either fibrinogen activity or antigen <0.1 g/L, and normal platelet count of 240.10 /L. Thrombin time and reptilase time were also significantly prolonged (>120 s; normal values below 20 s).\nThe patient had a history of several severe thromboses and bleeding episodes. Her bleeding history started with intracranial bleeding induced by severe head trauma suffered at 3 months old, which was followed by several trauma-induced hematomas, spontaneous meningeal hemorrhage at 11 years old, intra-alveolar pulmonary hemorrhage at 23, menorrhagia, two episodes of hemoperitoneum induced by ruptured ovarian cysts, six first-trimester miscarriages due to severe hemorrhagic complications, and acute unprovoked cerebellar hemorrhage at 30 years old. Most of the bleeding episodes that occurred during her childhood and youth were treated with cryoprecipitate and fresh frozen plasma. She was shown to be hepatitis C antibody- and RNA-positive, with normal liver enzyme levels. The patient was taking several supplements for iron deficiency anemia due to heavy menstrual blood loss, and refused prophylaxis with fibrinogen concentrates, as they require regular intravenous infusions. Moreover, she was working in the traveling family circus with a lifestyle of “perpetual traveler”, rendering clinical follow-up very difficult.\nAt the age of 30, she exhibited a spontaneous cerebellar hemorrhage and received her first replacement therapy with fibrinogen concentrates, after which she developed a proximal deep vein thrombosis (DVT) complicated by pulmonary embolism (PE) four days after the introduction of fibrinogen concentrate, while her plasma fibrinogen level was 1.2 g/L. The fibrinogen infusions were immediately stopped, and unfractionated heparin (UFH) was initiated. When her fibrinogen level dropped to <0.5 g/L, 24 h following withdrawal of the fibrinogen concentrate, fibrinogen replacement therapy was reinitiated, with a target plasma fibrinogen of 0.5–0.8 g/L, and UFH was concomitantly administered for a total duration of 6 weeks. No bleeding complications occurred, and her cerebellar bleeding was not aggravated during UFH therapy. The patient fully recovered from this episode.\nTwo years later, at 32 years, she presented an acute coronary syndrome (ACS) with an ulcerated atheromatous plaque in the left anterior descending coronary artery. However, due to there being only a limited perfusion defect and no occlusion on coronary angiography, reperfusion therapy was not initiated given her high risk of bleeding. She had no cardiovascular risk factors, except for slightly-elevated cholesterol levels. A combined treatment of low molecular weight heparin (LMWH) and fibrinogen was prescribed. On replacement therapy, the patient exhibited bilateral calf DVT, which was treated with LMWH until complete resolution of the venous clots, achieved in 10 days. Following hospital discharge, the patient pursued a treatment at home consisting of 40 mg atorvastatin per day, with a target LDL cholesterol level < 1 g/L. No aspirin was prescribed for this patient due to her high bleeding risk. As several thromboses were reported in the patient’s family, and given the known AT deficiency of her sister, thrombophilia testing was then performed, revealing heterozygous antithrombin (AT) deficiency at 65% by means of chromogenic assay (Biophen AT anti-(h)-Xa LRT, Hyphen BioMed, Neuville sur Oise, France). The reference AT in adults ranges between 80 and 120%. Genetic sequencing revealed a point mutation L131F in the 2nd exon of the AT gene. As a result, this proved to be a very rare case of combined afibrinogenemia and AT deficiency. Plasma AT was therefore measured in her brother, confirming similar combined inherited AT and fibrinogen deficiencies.\nThrombin generation was measured using Calibrated automated thrombin generation assay (Stago, les Asnières, France) in the presence of a low concentration of tissue factor 1pM, in accordance with the recent recommendations of the ISTH . Thrombin generation (TG) assay revealed the patent had a higher TG capacity compared to other afibrinogenemia patients . The area under the thrombin generation curve (ETP) representing the enzymatic activity of thrombin was very high (ETP = 2670 nM.min) in the patient, in accordance with her clinical history of thrombosis. AT deficiency was probably the main reason of the increased thrombin generation capacity in our patient. A slight TG decrease was observed following infusion of AT concentrate at 30 U/Kg . In light of these clinical and laboratory findings, we decided to normalize the patient’s AT level prior to any fibrinogen concentrate infusion, in an effort to reduce the risk of thrombosis related to replacement therapy.\nAt 49 years old, the patient consulted at the ER for severe acute chest pain. Her blood pressure on admission was 87/57 mmHg, her heart rate 87 bpm, and her physical examination unremarkable. Upon admission, laboratory tests revealed increased alanine aminotransferase activity (50 U/L [normal: 3–26 U/L]) and aspartate aminotransferase (121 U/L [normal: 6–18 U/L). Her troponin-T level was dramatically increased (24,693 ng/L [normal: <20 ng/L]). Her C-reactive protein was 62.6 mg/L (normal <5 mg/lL). Routine coagulation tests showed activated partial thromboplastin time (aPTT) >240 s and prothrombin time (PT) >120 s. The patient’s plasma fibrinogen level was undetectable for both activity and antigen assays. The electrocardiogram (ECG) was normal. Non-ST-elevated myocardial infarction (NSTEMI) was suspected. Echocardiography confirmed the diagnosis and revealed an impaired ejection fraction of 45%, with akinesia in the anteroseptal, anteromedial, and apical segments. The CT coronary angiogram revealed 80% stenosis in the common trunk of the left coronary artery and 50% stenosis in the anterior interventricular branch of the left coronary artery . The right coronary artery and circumflex coronary artery were normal. A diagnosis of NSTEMI was established, and double coronary artery bypass surgery was scheduled.\nThe surgery was performed, following replacement therapy with 30 U/Kg antithrombin concentrate (Aclotine®, LFB-Biomedicaments, Les Ulis, France) and 1.5 g fibrinogen (Clottafact®, LFB-Biomedicaments), along with UFH at the typical coronary bypass dosage. The surgery was successful, whilst carefully controlling the combined anticoagulant and procoagulant molecules. No excessive bleeding occurred. UFH was maintained for 3 weeks following surgery. Antithrombin and fibrinogen infusions were calculated following laboratory results with the aim of maintaining plasma AT >80% and fibrinogen between 0.5 and 1 g/L. All pro- and anti-coagulant treatments were discontinued 2 days before hospital discharge, on post-op Day 23. Two days after treatment withdrawal, the patient developed a segmental PE treated with LMWH in association with antithrombin and fibrinogen concentrates for 2 months, as described above.\nIn this patient who had suffered two acute coronary heart attacks, secondary prophylaxis with 75 mg aspirin/day was recommended, combined with antithrombin and fibrinogen infusions administered at least once a week, in order to keep plasma fibrinogen >0.5 g/L. However, the patient refused fibrinogen and AT prophylaxis, for his would require weekly injections. Therefore, antithrombotic prophylaxis with antiplatelet therapy (APT) was not initiated.\nFive months later, the patient was admitted to the ER for spontaneous left upper limb monoplegia associated with left-sided facial paralysis, dysarthria, and left homonymous hemianopia. Cerebral computed tomography (CT) revealed multiple hypodense ischemic lesions in the right frontal and parietal lobes associated with a thrombus in the right internal carotid artery. Echocardiogram, Holter ECG, and supra-aortic branch evaluation using Doppler ultrasonography disclosed no additional lesions indicative of stroke. On admission, plasma fibrinogen was <0.1 g/L, and daily aspirin at 75 mg was initiated. No fibrinogen replacement therapy was prescribed, given her several previous VTE episodes following fibrinogen concentrate infusions. The follow-up CT, performed one week after starting aspirin, revealed an acute subdural hematoma (SDH) measuring 27 mm, probably induced by aspirin. As the patient was asymptomatic, aspirin was immediately discontinued, and she was administered antithrombin and fibrinogen concentrates twice a week for 4 months, resulting in significant regression of the SDH to 10 mm in its largest diameter. Eventually, she accepted long-term antithrombin and fibrinogen prophylaxis based on weekly infusions (30 U/Kg and 1.5 g, respectively), rendering anti-thrombotic prophylaxis with aspirin again possible, which was very carefully reintroduced at low doses of 75 mg, arbitrarily, administered every 3 days. Under prophylaxis, her fibrinogen trough levels were ≥0.3 g/L. The patient has not reported any breakthrough bleeds with the current prophylactic regimen. No recent thrombosis has occurred and follow-up cerebral CTs have shown that the SDH is remaining stable.", + "fulltext_subclaims": [ + "The patient is a 49-year-old non-smoker female.", + "She has known afibrinogenemia.", + "She has antithrombin (AT) deficiency.", + "She was admitted to the emergency room for acute substernal chest pain.", + "She had a history of pyelonephritis.", + "She had treatment for a multinodular goiter.", + "She has congenital deafness.", + "Her parents were consanguineous.", + "Her father died from a surgically-induced pulmonary embolism.", + "Her brother has the same combined afibrinogenemia and AT deficiency.", + "Her sister died from pulmonary embolism during her first pregnancy.", + "Her sister had AT deficiency.", + "Afibrinogenemia was diagnosed when the patient was 3 months old.", + "DNA sequencing showed a homozygous (c.510 + 1G > T) substitution in the splicing site of the 4th intron of the fibrinogen alpha-chain.", + "Routine coagulation tests showed a prolonged activated partial thromboplastin time (>240 s).", + "Routine coagulation tests showed a prolonged prothrombin time (>120 s).", + "Fibrinogen activity and antigen were undetectable (<0.1 g/L).", + "The platelet count was 240.10 /L.", + "Thrombin time and reptilase time were significantly prolonged (>120 s).", + "The patient had a history of several severe thromboses and bleeding episodes.", + "She had intracranial bleeding induced by severe head trauma at 3 months old.", + "She had several trauma-induced hematomas.", + "She had a spontaneous meningeal hemorrhage at 11 years old.", + "She had intra-alveolar pulmonary hemorrhage at 23.", + "She had menorrhagia.", + "She had two episodes of hemoperitoneum induced by ruptured ovarian cysts.", + "She had six first-trimester miscarriages due to severe hemorrhagic complications.", + "She had an acute unprovoked cerebellar hemorrhage at 30 years old.", + "Most bleeding episodes were treated with cryoprecipitate and fresh frozen plasma.", + "She was hepatitis C antibody- and RNA-positive.", + "She had normal liver enzyme levels.", + "She was taking supplements for iron deficiency anemia.", + "She refused prophylaxis with fibrinogen concentrates.", + "She was working in the traveling family circus.", + "She had a spontaneous cerebellar hemorrhage at 30 years old.", + "She received her first replacement therapy with fibrinogen concentrates.", + "She developed a proximal deep vein thrombosis four days after fibrinogen concentrate introduction.", + "Her plasma fibrinogen level was 1.2 g/L at the time of the DVT.", + "Fibrinogen infusions were immediately stopped.", + "Unfractionated heparin was initiated.", + "Fibrinogen replacement therapy was reinitiated when her fibrinogen level dropped to <0.5 g/L.", + "The target plasma fibrinogen was 0.5–0.8 g/L.", + "Unfractionated heparin was administered for 6 weeks.", + "No bleeding complications occurred during UFH therapy.", + "She fully recovered from the cerebellar hemorrhage.", + "She presented an acute coronary syndrome at 32 years old.", + "Coronary angiography showed an ulcerated atheromatous plaque in the left anterior descending coronary artery.", + "Reperfusion therapy was not initiated due to high bleeding risk.", + "A combined treatment of low molecular weight heparin and fibrinogen was prescribed.", + "She exhibited bilateral calf DVT.", + "The DVT was treated with LMWH until complete resolution in 10 days.", + "She was prescribed 40 mg atorvastatin per day.", + "The target LDL cholesterol level was <1 g/L.", + "No aspirin was prescribed due to high bleeding risk.", + "Thrombophilia testing revealed heterozygous antithrombin deficiency at 65%.", + "The reference AT in adults ranges between 80 and 120%.", + "Genetic sequencing revealed a point mutation L131F in the 2nd exon of the AT gene.", + "This proved to be a very rare case of combined afibrinogenemia and AT deficiency.", + "Plasma AT was measured in her brother, confirming similar combined inherited AT and fibrinogen deficiencies.", + "Thrombin generation was measured using a Calibrated automated thrombin generation assay.", + "The area under the thrombin generation curve (ETP) was 2670 nM.min.", + "AT deficiency was probably the main reason of the increased thrombin generation capacity.", + "A slight TG decrease was observed following infusion of AT concentrate at 30 U/Kg.", + "The patient was decided to normalize AT level prior to fibrinogen concentrate infusion.", + "At 49 years old, the patient consulted at the ER for severe acute chest pain.", + "Her blood pressure on admission was 87/57 mmHg.", + "Her troponin-T level was dramatically increased (24,693 ng/L).", + "C-reactive protein was 62.6 mg/L.", + "Routine coagulation tests showed aPTT >240 s and PT >120 s.", + "The patient’s plasma fibrinogen level was undetectable.", + "NSTEMI was suspected.", + "Echocardiography confirmed the diagnosis.", + "The CT coronary angiogram revealed 80% stenosis in the common trunk of the left coronary artery.", + "A diagnosis of NSTEMI was established.", + "Double coronary artery bypass surgery was scheduled.", + "The surgery was performed following replacement therapy with 30 U/Kg antithrombin concentrate and 1.5 g fibrinogen.", + "UFH was maintained for 3 weeks following surgery.", + "Antithrombin and fibrinogen infusions were discontinued 2 days before hospital discharge.", + "Two days after treatment withdrawal, the patient developed a segmental PE.", + "The PE was treated with LMWH in association with antithrombin and fibrinogen concentrates for 2 months.", + "Secondary prophylaxis with 75 mg aspirin/day was recommended.", + "The patient refused fibrinogen and AT prophylaxis.", + "Antithrombotic prophylaxis with APT was not initiated.", + "Five months later, the patient was admitted for spontaneous left upper limb monoplegia.", + "Cerebral CT revealed multiple hypodense ischemic lesions.", + "Daily aspirin at 75 mg was initiated.", + "An acute subdural hematoma was revealed on follow-up CT.", + "Aspirin was immediately discontinued.", + "Antithrombin and fibrinogen concentrates were administered twice a week for 4 months.", + "The SDH regressed to 10 mm.", + "She accepted long-term antithrombin and fibrinogen prophylaxis.", + "Aspirin was reintroduced at low doses of 75 mg every 3 days.", + "Her fibrinogen trough levels were ≥0.3 g/L.", + "No recent thrombosis has occurred.", + "Follow-up cerebral CTs showed the SDH remaining stable." + ], + "summary": "We hereby report a case of combined afibrinogenemia and congenital antithrombin deficiency manifested by recurrent life-threatening bleeding, as well as spontaneous severe arterial occlusion, such as acute coronary syndrome and stroke, and venous thromboses like pulmonary embolism.Secondary fibrinogen prophylaxis is recommended following any initial life-threatening bleeding episode in patients with afibrinogenemia, yet the high associated risk of thrombosis illustrates the complexity of choosing the most effective prophylaxis strategy combining fibrinogen concentrate with antithrombotic agent for optimal protection against the risk of both severe bleeding and thrombosis. For our patient, the thrombin generation assay objectively confirmed her prothrombotic tendency.", + "summary_subclaims": [ + "The patient had combined afibrinogenemia and congenital antithrombin deficiency.", + "The patient had recurrent life-threatening bleeding.", + "The patient had spontaneous severe arterial occlusion.", + "The patient had acute coronary syndrome.", + "The patient had stroke.", + "The patient had venous thromboses like pulmonary embolism.", + "Secondary fibrinogen prophylaxis is recommended following any initial life-threatening bleeding episode in patients with afibrinogenemia.", + "The high associated risk of thrombosis illustrates the complexity of choosing the most effective prophylaxis strategy.", + "The most effective prophylaxis strategy combines fibrinogen concentrate with an antithrombotic agent.", + "The goal of the prophylaxis strategy is optimal protection against the risk of both severe bleeding and thrombosis.", + "The thrombin generation assay objectively confirmed the patient's prothrombotic tendency." + ] + }, + { + "id": "multiclinsum_test_320_en.txt", + "fulltext": "A 35-year-old African American man with no significant past medical history was referred to our neuromuscular clinic for frequent falls and concern for neuropathy. He first noticed a bilateral foot drop causing an abnormal gait and frequent falls at the age of 25. He experienced slowly progressive muscle weakness with the involvement of the hands by the age of 33. He had no sensory complaints and no muscle cramping or stiffness. His 38-year-old brother also had a bilateral foot drop that started in his 30s and bilateral hand weakness. There was no history of a similar condition in any other family members, including parents and two paternal half-sisters. His neurologic examination revealed normal cognition and cranial nerve function without tongue weakness, atrophy, or fasciculation. Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for finger extension 4/5, distal finger flexion 4/5, thumb abduction 3/5, hand interosseous muscles 4/5, hip flexion 5/5, ankle dorsiflexion 3/5, and ankle plantar flexion 4/5 bilaterally. He had muscle atrophy distally in all limbs with claw hands and pes cavus. Deep tendon reflexes were 2+ throughout except for absent Achilles tendon reflexes bilaterally. There was no percussion or handgrip myotonia, and the muscle tone was normal. Sensory examination was normal to pinprick, vibratory, and proprioceptive testing. He had a slow high steppage gait. He had bilateral contracture in the Achilles tendons with no gross spine deformity.", + "fulltext_subclaims": [ + "The patient is a 35-year-old African American man.", + "He has no significant past medical history.", + "He was referred to the neuromuscular clinic for frequent falls and concern for neuropathy.", + "He first noticed a bilateral foot drop causing an abnormal gait and frequent falls at the age of 25.", + "He experienced slowly progressive muscle weakness with the involvement of the hands by the age of 33.", + "He had no sensory complaints.", + "He had no muscle cramping or stiffness.", + "His 38-year-old brother also had a bilateral foot drop that started in his 30s.", + "His 38-year-old brother also had bilateral hand weakness.", + "There was no history of a similar condition in any other family members.", + "His neurologic examination revealed normal cognition.", + "Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for finger extension 4/5.", + "Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for distal finger flexion 4/5.", + "Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for thumb abduction 3/5.", + "Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for hand interosseous muscles 4/5.", + "Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for ankle dorsiflexion 3/5 bilaterally.", + "Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for ankle plantar flexion 4/5 bilaterally.", + "He had muscle atrophy distally in all limbs.", + "He had claw hands.", + "He had pes cavus.", + "Deep tendon reflexes were 2+ throughout except for absent Achilles tendon reflexes bilaterally.", + "He had a slow high steppage gait.", + "He had bilateral contracture in the Achilles tendons." + ], + "summary": "A 35-year-old African American man presented with insidious onset and progressive symmetric distal leg weakness followed by hand muscle atrophy and weakness since the age of 25. He had no muscle cramps or sensory complaints. His 38-year-old brother developed similar symptoms beginning in his early 30 s. On neurologic examination, the patient had distal weakness and atrophy in all limbs, claw hands, pes cavus, absent Achilles reflexes, and normal sensory examination. Electrodiagnostic studies revealed absent/reduced compound motor action potential amplitudes distally with normal sensory responses with no neuromyotonia. His sural nerve biopsy showed a chronic non-specific axonal neuropathy, and a biopsy of the tibialis anterior muscle demonstrated myopathic features and several muscle fibers harboring rimmed vacuoles without inflammation in addition to chronic denervation changes. A homozygous variant, p.I63N (c.188T > A), in the HINT1 gene was found in both brothers.", + "summary_subclaims": [ + "The patient is a 35-year-old African American man.", + "He had insidious onset and progressive symmetric distal leg weakness.", + "He had hand muscle atrophy and weakness since the age of 25.", + "He had no muscle cramps.", + "He had no sensory complaints.", + "His 38-year-old brother developed similar symptoms beginning in his early 30 s.", + "On neurologic examination, the patient had distal weakness and atrophy in all limbs.", + "On neurologic examination, the patient had claw hands.", + "On neurologic examination, the patient had pes cavus.", + "On neurologic examination, the patient had absent Achilles reflexes.", + "On neurologic examination, the patient had a normal sensory examination.", + "Electrodiagnostic studies revealed absent/reduced compound motor action potential amplitudes distally.", + "Electrodiagnostic studies showed normal sensory responses.", + "Electrodiagnostic studies showed no neuromyotonia.", + "The sural nerve biopsy showed a chronic non-specific axonal neuropathy.", + "A biopsy of the tibialis anterior muscle demonstrated myopathic features.", + "A biopsy of the tibialis anterior muscle showed several muscle fibers harboring rimmed vacuoles.", + "A biopsy of the tibialis anterior muscle showed no inflammation.", + "A biopsy of the tibialis anterior muscle showed chronic denervation changes.", + "A homozygous variant, p.I63N (c.188T > A), in the HINT1 gene was found in both brothers." + ] + }, + { + "id": "multiclinsum_test_2362_en.txt", + "fulltext": "Mrs RB, a 25-year-old Kuwaiti woman primigravida, married for 18 months, presented to the Maternity Hospital, Kuwait, at 31 weeks of gestation with rupture of membranes of 3 hours duration. This pregnancy was spontaneous and resulted from a non-consanguineous marriage and was followed up in the private health care service. The antenatal period had been uneventful until this emergency presentation. There was no evidence of antenatal ultrasonography in the private health services as the patient did not present any information or reports of such an investigation. She was not known to have diabetes mellitus. Her past surgical/medical/gynecological history was not contributory.\nAt admission, the patient was calm, afebrile and the vital signs were normal. There was no abnormality in the respiratory and cardiovascular systems. Obstetric examination confirmed a 31 weeks of gestation, the fetus in breech presentation and the presence of normal fetal heart sounds. She was managed conservatively, and she was placed on prophylactic antibiotics. A course of dexamethasone injections was given, and she was transferred to the antenatal ward. After 8 hours, the patient was readmitted to the labor ward complaining of labor pains, and pelvic examination revealed that the cervix was fully dilated with a frank breech presentation at station 1 cm below the ischial spine. An assisted breech delivery of a premature baby, birth weight 1570 g, was conducted. The Apgar scores of 3 and 9 were recorded, and an endotracheal tube was inserted into the baby.\nThe baby was discovered to have the following abnormalities:\nfusion of both lower limbs ; ambiguous genitalia ; cloacal anomaly and tracheoesophageal fistula with atresia Active resuscitation of the new born was undertaken, the baby was then transferred to the neonatal intensive care unit. Fluorescent in situ hybridization (FISH) study was conducted on the baby, and it revealed 46 XX chromosome patterns with no numerical or structural abnormalities. Skeletal survey showed that the baby had two femoral bones, two tibias, two fibulas with sacral segmentation defect with 13 bilateral ribs and a normal vertebrae. The baby passed urine through a single partial opening over the sacral area.\nExploratory laparotomy was performed, which showed distal jejunal atresia with dilated proximal bowel of 10–15 cm. The distal colon was atretic. The esophagus was ligated, 15 cm of dilated proximal loop was resected and jejunostomy along with gastrostomy was performed. Renal ultrasound showed left polycystic kidney, and the right kidney was not visualized (query for right ectopic kidney). No magnetic resonance imaging (MRI) was performed on the baby. The baby was discharged after 123 days to continue medical treatment in the USA.\nThere was a discussion between two of the authors (FAH and AAA) and the parents about the authors’ intention to make a report of the case using all the information provided and the illustrations/pictures/X-rays of the neonate, and the parents gave their written informed consent for such a publication effort.", + "fulltext_subclaims": [ + "Mrs RB is a 25-year-old Kuwaiti woman.", + "She is a primigravida.", + "She presented at 31 weeks of gestation.", + "She had rupture of membranes of 3 hours duration.", + "The pregnancy was spontaneous.", + "The pregnancy resulted from a non-consanguineous marriage.", + "She was followed up in the private health care service.", + "There was no evidence of antenatal ultrasonography in the private health services.", + "She was not known to have diabetes mellitus.", + "Her past surgical/medical/gynecological history was not contributory.", + "At admission, she was calm and afebrile.", + "Obstetric examination confirmed 31 weeks of gestation.", + "The fetus was in breech presentation.", + "She was managed conservatively.", + "She was placed on prophylactic antibiotics.", + "A course of dexamethasone injections was given.", + "After 8 hours, she was readmitted to the labor ward.", + "Pelvic examination revealed the cervix was fully dilated.", + "An assisted breech delivery of a premature baby was conducted.", + "The baby's birth weight was 1570 g.", + "The Apgar scores were 3 and 9.", + "An endotracheal tube was inserted into the baby.", + "The baby had fusion of both lower limbs.", + "The baby had ambiguous genitalia.", + "The baby had a cloacal anomaly.", + "The baby had tracheoesophageal fistula with atresia.", + "Fluorescent in situ hybridization (FISH) study revealed 46 XX chromosome patterns.", + "The FISH study showed no numerical or structural abnormalities.", + "The baby passed urine through a single partial opening over the sacral area.", + "Exploratory laparotomy showed distal jejunal atresia.", + "The distal colon was atretic.", + "The esophagus was ligated.", + "15 cm of dilated proximal loop was resected.", + "Jejunostomy along with gastrostomy was performed.", + "Renal ultrasound showed left polycystic kidney.", + "The right kidney was not visualized.", + "No magnetic resonance imaging (MRI) was performed on the baby.", + "The baby was discharged after 123 days.", + "The baby was to continue medical treatment in the USA.", + "The parents gave their written informed consent for a publication effort." + ], + "summary": "Mrs RB, a Kuwaiti woman primigravida, married to a non-consanguineous husband, had uneventful antenatal care in a private health service, until she was admitted to the Maternity Hospital, Kuwait, at 31 weeks of gestation with a 3-hour history of ruptured membranes. She had a negative family history for diabetes mellitus, and her past surgical/medical/gynecological history was noncontributory. General physical examination revealed a healthy parturient with normal vital signs, clear lungs and normal heart sounds. Obstetric examination revealed a fundal height compatible with the gestational age; there was a single living fetus in breech presentation; she was not in labor. The mother was managed conservatively with antibiotics and dexamethasone injections. Labor ensued later, progressing rapidly to the second stage. Assisted breech delivery was performed, and a live baby, birth weight 1570 g and Apgar score 3/9, was delivered. The neonate had multiple congenital abnormalities, including fusion of both lower limbs, ambiguous genitalia, cloacal anomaly and tracheoesophageal fistula. The neonate was admitted to the neonatal intensive care unit, fully investigated, managed medically and surgically and eventually discharged home after a hospital stay of 123 days for further management.", + "summary_subclaims": [ + "Mrs RB is a Kuwaiti woman primigravida.", + "She was married to a non-consanguineous husband.", + "She had uneventful antenatal care in a private health service.", + "She was admitted to the Maternity Hospital, Kuwait, at 31 weeks of gestation.", + "She had a 3-hour history of ruptured membranes.", + "She had a negative family history for diabetes mellitus.", + "Her past surgical/medical/gynecological history was noncontributory.", + "General physical examination revealed a healthy parturient with normal vital signs.", + "Obstetric examination revealed a fundal height compatible with the gestational age.", + "There was a single living fetus in breech presentation.", + "She was not in labor.", + "The mother was managed conservatively with antibiotics and dexamethasone injections.", + "Labor ensued later, progressing rapidly to the second stage.", + "Assisted breech delivery was performed.", + "A live baby was delivered.", + "The baby's birth weight was 1570 g.", + "The baby's Apgar score was 3/9.", + "The neonate had multiple congenital abnormalities.", + "The neonate had fusion of both lower limbs.", + "The neonate had ambiguous genitalia.", + "The neonate had a cloacal anomaly.", + "The neonate had a tracheoesophageal fistula.", + "The neonate was admitted to the neonatal intensive care unit.", + "The neonate was fully investigated.", + "The neonate was managed medically and surgically.", + "The neonate was eventually discharged home.", + "The neonate's hospital stay was 123 days." + ] + }, + { + "id": "multiclinsum_test_1448_en.txt", + "fulltext": "A 76-year-old woman had an 8-year history of atrial fibrillation (AF) and severe TR. Her history included mild hypothyroidism and right upper lobectomy for lung carcinoma 11 years previously. For 2 years, she had complained of shortness of breath when lying in the left lateral decubitus position. She had felt dyspnea after mild exercise for 9 months. Recently, she had a sense of abdominal fullness. Although administration of diuretics was started, her symptoms did not completely improve, and she was referred to our department for surgical treatment. The follow-up chest X-ray showed a gradually protruding right-side shadow of the cardiac silhouette, and the cardiothoracic ratio on the chest X-ray reached 88% . The electrocardiogram showed AF with low fibrillatory wave amplitude. Echocardiography showed an enlarged right ventricular (RV) cavity and mild paradoxical motion of the ventricular septum. The tricuspid valve had no findings of an organic and constructive abnormality, with no severe tethering. The annular size of the tricuspid valve was 50 mm, and the tricuspid annular plane systolic excursion was 21 mm . Repeated preoperative cardiac catheterization showed slightly elevated wedge pressure with mild pulmonary hypertension, although LV function was preserved with a cardiac index of 4.0 . There was no L-R shunt disease. Computed tomography (CT) findings showed that the maximum size of the RA reached 121 mm . The change in dimension of the RA by CT showed that the size of the RA increased with time . Blood tests showed no liver dysfunction.\nSurgery was performed via median sternotomy. The pericardium was extremely thin on the RA side without any defect. There was no adherence in the pericardial cavity. Cardiopulmonary bypass was established by ascending aorta cannulation with bicaval drainage. The RA was extremely thin and the tricuspid valve annulus was enlarged, with a diameter of 55 mm, but there was no tricuspid structural abnormality. Tricuspid annuloplasty was performed on the beating heart using a 28-mm Carpentier-Edwards Physio tricuspid annuloplasty ring (Edwards Lifesciences, Irvine, CA, USA). Plication of the enlarged RA was performed, mainly at the interatrial septum, the free RA wall, including the appendage, and the space between the inferior vena cava and the tricuspid ring, in addition to the free RA wall, including the appendage . Additionally, closure of the left atrial appendage from the outside was performed to prevent left atrial thrombus formation. All procedures were performed on the beating heart. The postoperative course was uneventful. The pathological findings of the RA wall demonstrated thinning of the myocardium, inflammatory cell infiltrate, and few cardiomyocytes . Postoperative X-ray and CT showed reduced cardiac silhouette and RA volume . Postoperative echocardiography showed an ejection fraction of 58% and mild TR with a pressure gradient of 29 mmHg . The postoperative value of tricuspid annular plane systolic excursion (TAPSE) decreased after the operation. However, the patient’s symptoms were completely resolved, and she was discharged 3 weeks after surgery. The patient is doing well 2 years after surgery.", + "fulltext_subclaims": [ + "The patient is a 76-year-old woman.", + "She had an 8-year history of atrial fibrillation.", + "She had a 2-year history of shortness of breath when lying in the left lateral decubitus position.", + "She had a 9-month history of dyspnea after mild exercise.", + "She had a sense of abdominal fullness recently.", + "The administration of diuretics did not completely improve her symptoms.", + "The electrocardiogram showed atrial fibrillation with low fibrillatory wave amplitude.", + "Echocardiography showed an enlarged right ventricular cavity.", + "Echocardiography showed mild paradoxical motion of the ventricular septum.", + "The tricuspid valve had no findings of an organic and constructive abnormality.", + "The annular size of the tricuspid valve was 50 mm.", + "The tricuspid annular plane systolic excursion was 21 mm.", + "Computed tomography showed the maximum size of the right atrium was 121 mm.", + "The size of the right atrium increased with time.", + "Blood tests showed no liver dysfunction.", + "Surgery was performed via median sternotomy.", + "The pericardium was extremely thin on the right atrial side without any defect.", + "Tricuspid annuloplasty was performed on the beating heart using a 28-mm Carpentier-Edwards Physio tricuspid annuloplasty ring.", + "Plication of the enlarged right atrium was performed.", + "Closure of the left atrial appendage from the outside was performed.", + "All procedures were performed on the beating heart.", + "The postoperative course was uneventful.", + "The pathological findings of the right atrial wall demonstrated thinning of the myocardium.", + "Postoperative X-ray and CT showed reduced cardiac silhouette and right atrial volume.", + "Postoperative echocardiography showed an ejection fraction of 58%.", + "Postoperative echocardiography showed mild tricuspid regurgitation with a pressure gradient of 29 mmHg.", + "The postoperative value of tricuspid annular plane systolic excursion decreased after the operation.", + "The patient’s symptoms were completely resolved.", + "She was discharged 3 weeks after surgery.", + "The patient is doing well 2 years after surgery." + ], + "summary": "A 76-year-old woman was followed up due to atrial fibrillation and tricuspid regurgitation for 8 years. A follow-up echocardiogram showed progressive dilatation of the right atrium. Because of the development of shortness of breath, right atrial plication and tricuspid valve repair were performed. Tricuspid annuloplasty was performed on the beating heart with the use of a 28-mm Carpentier-Edwards Physio tricuspid annuloplasty ring. Plication of the enlarged right atrium was performed at the interatrial septum, the free right atrium wall including the appendage, and the space between the inferior vena cava and the tricuspid ring. Closure of the left atrial appendage was performed from outside to prevent left atrial thrombus formation. Postoperative X-ray and computed tomography showed reduced cardiac silhouette and right atrial volume. The patient was discharged uneventfully and returned for follow-up visits with improved symptoms.", + "summary_subclaims": [ + "The patient was a 76-year-old woman.", + "She had atrial fibrillation and tricuspid regurgitation for 8 years.", + "A follow-up echocardiogram showed progressive dilatation of the right atrium.", + "Shortness of breath developed.", + "Right atrial plication and tricuspid valve repair were performed.", + "Tricuspid annuloplasty was performed on the beating heart.", + "A 28-mm Carpentier-Edwards Physio tricuspid annuloplasty ring was used.", + "Plication of the enlarged right atrium was performed at the interatrial septum.", + "Plication of the enlarged right atrium was performed at the free right atrium wall including the appendage.", + "Plication of the enlarged right atrium was performed at the space between the inferior vena cava and the tricuspid ring.", + "Closure of the left atrial appendage was performed from outside.", + "Postoperative X-ray showed reduced cardiac silhouette.", + "Postoperative computed tomography showed reduced right atrial volume.", + "The patient was discharged uneventfully.", + "The patient returned for follow-up visits.", + "The patient had improved symptoms." + ] + }, + { + "id": "multiclinsum_test_2846_en.txt", + "fulltext": "A 40-year-old woman was admitted for ENT, head and neck surgery emergency care with a 02-week history of fever, pharyngeal foreign body sensation, odynophagia and right-sided neck pain and swelling. She had no clear history of malignancy, central venous catheterization, coagulation disorders, cervical trauma or any foreign body ingestion, genetic and family histories were unremarkable. Physical examination revealed erythematous swelling over the right side of the neck. Nasofibroscopy showed pyriform sinus edema with purulent secretions filling the hypopharynx. Complete blood count (CBC) showed his white blood cell count was (17,000)/mm3 with predominant neutrophil, C-reactive protein was 62 mg/l. Contrast-enhanced computed tomography scan revealed Abnormal low attenuation within the parapharyngeal space and along the carotid space indicates cellulitis , with a vascular filling defect in the left internal jugular vein to left subclavian vein region, penetrated by a metal density foreign body (, ). On the basis of the above findings, we diagnosed the patient as having an ingested foreign body complicated by cervical cellulitis and thrombosis of the internal jugular vein.\nBecause of the cervical cellulitis and the presence of a foreign body, an intravenous probabilistic antibiotic therapy is initiated immediately consisting on third-generation cephalosporins 2 g/24 h, Metronidazole 500 mg/8 h and aminoglycoside 160 mg/24 h, 02 h later a qualified surgeon with 20 years of experience decided to proceed to surgery for better exposure and also effective drainage of fluid collection. Via an incision anterior to the left sternocleidomastoid muscle, the parapharyngeal space was explored and the carotid sheath was opened. A 4 cm sewing needle was found extending transversely into the right jugular vein and the sternocleidomastoid muscle at the level of the thyroid cartilage and thrombosed right internal jugular vein. After removal of the needle, unfractionated heparin was administered intravenously, then the internal jugular vein was ligated proximal and distal to the site of injury. Drainage of abscess cavities and debridement of necrotic tissues were done, and samples were sent for culture. A Penrose drain was inserted, the skin was closed with separate stitches, and systemic heparinization was ceased. The pus culture did not show any organism and the intravenous probabilistic antibiotic therapy was continued. The postoperative course was uneventful, and liquid diet was started on the 3th postoperative day. After a normal barium esophagram, the patient was discharged on the 7th postoperative day and was ordered to complete 02 weeks of oral antibiotic therapy. Within a month the swelling completely disappeared, dysphagia improved, and the patient became normal. The patient is in the 12th month of her follow-up and no complications have been observed during this period.", + "fulltext_subclaims": [ + "The patient is a 40-year-old woman.", + "She was admitted for ENT, head and neck surgery emergency care.", + "She had a 02-week history of fever.", + "She had a 02-week history of pharyngeal foreign body sensation.", + "She had a 02-week history of odynophagia.", + "She had a 02-week history of right-sided neck pain and swelling.", + "She had no clear history of malignancy.", + "She had no clear history of central venous catheterization.", + "She had no clear history of coagulation disorders.", + "She had no clear history of cervical trauma.", + "She had no clear history of any foreign body ingestion.", + "Physical examination revealed erythematous swelling over the right side of the neck.", + "Nasofibroscopy showed pyriform sinus edema.", + "Nasofibroscopy showed purulent secretions filling the hypopharynx.", + "CBC showed white blood cell count of 17,000/mm3.", + "CBC showed predominant neutrophil.", + "C-reactive protein was 62 mg/l.", + "Contrast-enhanced computed tomography scan revealed abnormal low attenuation within the parapharyngeal space.", + "Contrast-enhanced computed tomography scan revealed abnormal low attenuation along the carotid space.", + "Contrast-enhanced computed tomography scan indicated cellulitis.", + "Contrast-enhanced computed tomography scan showed a vascular filling defect in the left internal jugular vein to left subclavian vein region.", + "Contrast-enhanced computed tomography scan showed a metal density foreign body.", + "The diagnosis was an ingested foreign body complicated by cervical cellulitis.", + "The diagnosis was an ingested foreign body complicated by thrombosis of the internal jugular vein.", + "Intravenous probabilistic antibiotic therapy was initiated immediately.", + "The intravenous probabilistic antibiotic therapy consisted of third-generation cephalosporins 2 g/24 h.", + "The intravenous probabilistic antibiotic therapy consisted of Metronidazole 500 mg/8 h.", + "The intravenous probabilistic antibiotic therapy consisted of aminoglycoside 160 mg/24 h.", + "A qualified surgeon with 20 years of experience decided to proceed to surgery.", + "The surgery was performed 02 h after initiation of antibiotics.", + "The surgery was performed for better exposure.", + "The surgery was performed for effective drainage of fluid collection.", + "An incision was made anterior to the left sternocleidomastoid muscle.", + "The parapharyngeal space was explored.", + "The carotid sheath was opened.", + "A 4 cm sewing needle was found extending transversely into the right jugular vein.", + "A 4 cm sewing needle was found extending transversely into the sternocleidomastoid muscle.", + "The needle was found at the level of the thyroid cartilage.", + "The right internal jugular vein was thrombosed.", + "The needle was removed.", + "Unfractionated heparin was administered intravenously.", + "The internal jugular vein was ligated proximal to the site of injury.", + "The internal jugular vein was ligated distal to the site of injury.", + "Drainage of abscess cavities was done.", + "Debridement of necrotic tissues was done.", + "Samples were sent for culture.", + "A Penrose drain was inserted.", + "The skin was closed with separate stitches.", + "Systemic heparinization was ceased.", + "The pus culture did not show any organism.", + "The intravenous probabilistic antibiotic therapy was continued.", + "The postoperative course was uneventful.", + "Liquid diet was started on the 3th postoperative day.", + "A normal barium esophagram was obtained.", + "The patient was discharged on the 7th postoperative day.", + "The patient was ordered to complete 02 weeks of oral antibiotic therapy.", + "Within a month the swelling completely disappeared.", + "Dysphagia improved.", + "The patient became normal.", + "The patient is in the 12th month of her follow-up.", + "No complications have been observed during this period." + ], + "summary": "We report a case of a 40 years old patient, for acute cervical cellulitis in a context of odynophagia and fever, a CT scan revealed a jugular vein thrombosis, penetrated by a metal density foreign body. The diagnosis of ingested foreign body complicated by cervical cellulitis and thrombosis of the internal jugular vein was made. The patient underwent neck surgery with intravenous antibiotics. The postoperative course was uneventful, after one year of follow-up, no complications have been observed.", + "summary_subclaims": [ + "The patient is a 40 years old.", + "The patient had acute cervical cellulitis.", + "The patient had odynophagia.", + "The patient had fever.", + "A CT scan revealed a jugular vein thrombosis.", + "The CT scan showed a metal density foreign body.", + "The diagnosis was ingested foreign body complicated by cervical cellulitis and thrombosis of the internal jugular vein.", + "The patient underwent neck surgery.", + "The patient received intravenous antibiotics.", + "The postoperative course was uneventful.", + "After one year of follow-up, no complications have been observed." + ] + }, + { + "id": "multiclinsum_test_2844_en.txt", + "fulltext": "A 31-year-old male patient attended the outpatient clinic of our hospital’s reproductive medicine center with a complaint of “three years without pregnancy despite not using contraception”.\nThree years without pregnancy.\nIn 2014, the patient’s wife had undergone an induced abortion, and the patient had undergone a high ligation of his left varicocele in 2018; however, sperm quality did not appear to have improved upon re-examination after the surgery.\nThe patient has no history of hypertension or diabetes. Her parents were non-consanguineous and had no family history of hereditary diseases.\nIn terms of appearance, the patient’s height was 165 cm, weight was 65 kg, and body mass index was 23.88 Kg/m2. Specialist examination showed that his pubic hair was distributed like an inverted triangle, his penis measured approximately 6 cm long when flaccid, the urethral opening showed no visible abnormalities, bilateral testicular volume was approximately 12 mL with a tough texture, the bilateral vas deferens and epididymis showed no observable abnormalities upon palpation, and no varicocele was found.\nThrough two routine semen analyses and rapid morphology staining (Diff-Quik method), the patient was diagnosed with secondary infertility and ASS. Given the patient’s informed consent, 5 mL of his peripheral blood was collected. Our study was approved by the Ethics Committee of the Shenzhen Maternal and Child Health Care Hospital and was conducted with the patient’s informed consent.\nAfter three to five days of abstinence, the patient masturbated to enable sperm extraction, which was liquified in a water bath at 37℃. Analyses were conducted twice according to the WHO laboratory manual (Fifth Edition). Eosin staining was conducted to detect sperm viability and sperm morphology was determined after staining the sperm smear using a rapid staining solution (Diff-Quik method), and 200 sperms were counted. Morphological defects were divided into four categories: normal, abnormal head-neck configuration, detached heads, and headless, and the percentage of each category was calculated.\nPeripheral blood was collected and used for karyotype analysis through cell culture and Y chromosome microdeletion testing through PCR-capillary electrophoresis.\nFor exome sequencing, we fragmented 1-3 μg of genomic DNA, extracted from each sample, to an average size of 180 bp with a Bioruptorsonicator (Diagenode). Paired-end sequencing libraries then were prepared using a DNA sampleprep reagent set 1 (NEBNext). Library preparation included end repair, adapter ligation and PCRenrichment, and was carried out as recommendedby Illumina protocols.\nThe amplified DNA was captured use GenCap Deafness capture kit (MyGenostics GenCap Enrichment technologies). The DNA probes were designed to tile along the exon regions and the known non-exon pathogenic region of human genes. The capture experiment was conducted according to manufacturer’s protocol. The PCR product was purified using SPRI beads (Beckman Coulter) according to manufacturer’s protocol. The enrichment libraries were sequenced on Illumina HiSeq X ten sequencer for paired read 150 bp.\nAfter sequencing, the rawdata were saved as a FASTQ format, then followed the bioinformatics analysis,the data would be transformed to VCF format, variants were further annotated by ANNOVA Rand associated with multiple databases, such as,1000 genome, ESP6500, dbSNP , EXAC, Inhouse (MyGenostics), HGMD, and predicted by SIFT, PolyPhen-2, MutationTaster, GERP++.\nfive steps using to select the potential pathogenic mutations in downstream analysis: (1) Mutation reads should be more than 5, mutation ration should be no less than 30%; (2) Removing the mutation, the frequency of which showed more than 5% in 1000 g, ESP6500 and Inhouse database; (3) If the mutations existed in InNormal database (MyGenostics), then dropped; (4) Removing the synonymous; and (5) After (1),(2),(3), if the mutations were synonymous and they were reported in HGMD, left them. When finished above jobs, the mutations which were left should be the pathogenic mutations.\nWhen performed under conditions of low sperm activity, neither method revealed morphologically normal sperm. High percentages of sperm with abnormal head-neck connections, detached heads, and headless sperm were observed, indicating complete teratozoospermia with oligoasthenozoospermia . Eosin staining showed that there were no normal sperms in the semen; instead, some were intact (with head and tail at an angle), most had headless, and very few had sperm heads without tails .\nPeripheral blood karyotype analysis (G banding): 46, XY; Y chromosome microdeletion: no deletion observed.\nWe analyzed exons and adjacent splicing regions of genes associated with male infertility, with a focus on known pathogenic genes related to severe oligozoospermia and the patient’s clinical background. We found two heterozygous variants of the PMFBP1 gene : PMFBP1c.414+1G>T (p.?) and PMFBP1c.393del (p.C132Afs*3). The heterozygous splicing variant c.414+1G>T (p.?) of gene PMFBP1 was in intron 4 (the PMFBP1 gene contains 20 introns) and was likely to interfere with the mRNA splicing signal. This was a classical splicing variant, which may lead to loss of amino acids but might not destroy the reading frame. The heterozygous frameshift variant c.393del (p.C132Afs*3) of the PMFBP1 gene caused the replacement of cysteine by alanine at position 132, followed by a frameshift and a premature stop codon, resulting in the early termination of protein coding. The detected frameshift mutation may lead to > 10% amino acid loss, resulting in the occurrence of nonsense-mediated mRNA decay, which may be a non-functional mutation. According to the American College of Medical Genetics and Genomics Guidelines, these variants are probable pathogenic variants .", + "fulltext_subclaims": [ + "The patient is a 31-year-old male.", + "The patient attended the outpatient clinic of the hospital’s reproductive medicine center.", + "The patient’s complaint was three years without pregnancy despite not using contraception.", + "Three years without pregnancy.", + "In 2014, the patient’s wife had undergone an induced abortion.", + "The patient had undergone a high ligation of his left varicocele in 2018.", + "Sperm quality did not appear to have improved upon re-examination after the surgery.", + "The patient has no history of hypertension.", + "The patient has no history of diabetes.", + "The patient’s height was 165 cm.", + "The patient’s weight was 65 kg.", + "The patient’s body mass index was 23.88 kg/m2.", + "The patient’s pubic hair was distributed like an inverted triangle.", + "The patient’s penis measured approximately 6 cm long when flaccid.", + "Bilateral testicular volume was approximately 12 mL.", + "The patient was diagnosed with secondary infertility.", + "The patient was diagnosed with ASS.", + "5 mL of the patient’s peripheral blood was collected.", + "The study was approved by the Ethics Committee of the Shenzhen Maternal and Child Health Care Hospital.", + "The patient provided informed consent.", + "The patient masturbated to enable sperm extraction after three to five days of abstinence.", + "Sperm was liquified in a water bath at 37℃.", + "Analyses were conducted twice according to the WHO laboratory manual (Fifth Edition).", + "Eosin staining was conducted to detect sperm viability.", + "Sperm morphology was determined after staining the sperm smear using a rapid staining solution (Diff-Quik method).", + "200 sperms were counted.", + "Morphological defects were divided into four categories: normal, abnormal head-neck configuration, detached heads, and headless.", + "The percentage of each category was calculated.", + "Peripheral blood was collected and used for karyotype analysis through cell culture.", + "Y chromosome microdeletion testing was conducted through PCR-capillary electrophoresis.", + "Genomic DNA was fragmented to an average size of 180 bp with a Bioruptorsonicator.", + "Paired-end sequencing libraries were prepared using a DNA sample prep reagent set.", + "Library preparation included end repair, adapter ligation, and PCR enrichment.", + "The amplified DNA was captured using the GenCap Deafness capture kit.", + "The DNA probes were designed to tile along the exon regions and the known non-exon pathogenic region of human genes.", + "The capture experiment was conducted according to the manufacturer’s protocol.", + "The PCR product was purified using SPRI beads.", + "The enrichment libraries were sequenced on an Illumina HiSeq X ten sequencer.", + "The raw data were saved as a FASTQ format.", + "Variants were annotated by ANNOVAR and associated with multiple databases.", + "Five steps were used to select potential pathogenic mutations.", + "Mutation reads should be more than 5, mutation ratio should be no less than 30%.", + "Mutations with a frequency of more than 5% in 1000 genome, ESP6500, and Inhouse database were removed.", + "If the mutations existed in InNormal database, they were dropped.", + "Synonymous mutations were removed.", + "If the mutations were synonymous and reported in HGMD, they were left.", + "When performed under conditions of low sperm activity, neither method revealed morphologically normal sperm.", + "High percentages of sperm with abnormal head-neck connections, detached heads, and headless sperm were observed.", + "Eosin staining showed that there were no normal sperms in the semen.", + "Some sperm were intact (with head and tail at an angle).", + "Most sperm had headless.", + "Very few sperm had heads without tails.", + "Peripheral blood karyotype analysis (G banding): 46, XY.", + "Y chromosome microdeletion: no deletion observed.", + "Two heterozygous variants of the PMFBP1 gene were found.", + "The heterozygous splicing variant c.414+1G>T (p.?) of gene PMFBP1 was in intron 4.", + "The heterozygous splicing variant c.414+1G>T (p.?) was likely to interfere with the mRNA splicing signal.", + "The heterozygous frameshift variant c.393del (p.C132Afs*3) of the PMFBP1 gene caused the replacement of cysteine by alanine at position 132.", + "The frameshift variant caused a premature stop codon.", + "The detected frameshift mutation may lead to > 10% amino acid loss.", + "The detected frameshift mutation may be a non-functional mutation.", + "According to the American College of Medical Genetics and Genomics Guidelines, these variants are probable pathogenic variants." + ], + "summary": "We reported the case of a male patient with secondary infertility whose sperm showed typical ASS upon morphological analysis. Whole-exome sequencing was performed on the patient's peripheral blood, which revealed two heterozygous variants of the PMFBP1 gene: PMFBP1c.414+1G>T (p.?) and PMFBP1c.393del (p.C132Afs*3).", + "summary_subclaims": [ + "The patient was a male with secondary infertility.", + "The patient's sperm showed typical acrosome reaction (ASS) upon morphological analysis.", + "Whole-exome sequencing was performed on the patient's peripheral blood.", + "The patient had two heterozygous variants of the PMFBP1 gene.", + "One variant was PMFBP1c.414+1G>T (p.?).", + "The other variant was PMFBP1c.393del (p.C132Afs*3)." + ] + }, + { + "id": "multiclinsum_test_2826_en.txt", + "fulltext": "During the COVID-19 pandemic, in April 2020, a 55-year-old Caucasian man presented to the emergency department of our institution with fever up to 38.6 °C, cough and shortness of breath. He had a history of ischemic heart disease, diabetes, arterial hypertension, severe obesity, asthma, and he was a smoker. Because of respiratory failure, oxygen therapy was promptly administered via a Venturi mask at 35%. Bilateral crackles were present during chest auscultation; there were no other relevant findings on physical examination. Blood chemistry revealed a high white cell count and high levels of both C-reactive protein (CRP) and D-dimer (the latter being 1652 mcg/l; normal: 0–550 mcg/l). Due to the ongoing pandemic and based on his symptoms, the patient was initially managed as a suspected case of COVID-19, even though two consecutive nasopharyngeal swabs were negative for SARS-CoV-2. High resolution computed tomography (HRCT) of the chest, before and after intravenous injection of iodinated contrast medium, was obtained. The exam showed multiple small hazy nodular opacities diffusely distributed throughout both lung fields, with no specific lobar preference . The nodules were centrilobular, with a linear branching pattern and a “tree-in-bud” appearance, mainly visible in the lower left lung field . CT also showed slightly enlarged mediastinal lymph nodes, without sign of necrosis, of a suspected reactive/inflammatory nature. The HRCT findings were not considered indicative of COVID-19 pneumonia.\nA possible diagnosis of miliary tuberculosis or other diffuse infectious/inflammatory disease was made and the patient was transferred to our respiratory unit for further investigations. Past medical history revealed no hemoptysis, chest pain or weight loss. The patient reported that during the pandemic he had decided to live in the damp basement of his house, to be isolated from his family, and that he used to work there for several hours a day. This occurred six weeks before the onset of symptoms and it has been the only major change in his daily life.\nSputum was negative for acid-fast bacilli in three specimens, and both Mantoux and QuantiFERON tests were negative, such that a diagnosis of tuberculosis was excluded. Pneumonia due to Legionella sp., Mycoplasma sp. or Chlamydia sp. infection was excluded as were HIV infection and autoimmune disease. Another possible diagnosis was secondary neoplasm of the lung, but a whole-body CT scan did not reveal any malignancy. An antibiotic therapy course was empirically started with ceftriaxone 2 g a day and azithromycin 500 mg once a day for seven days. Three weeks after the hospital admission, the patient repeated a non-enhanced chest CT scan that showed persistence of the pattern described above. Antinuclear and antineutrophilic cytoplasmic antibody tests were negative. The patient’s clinical condition slightly improved: he did not present with fever, and oxygen therapy via Venturi mask was promptly reduced to 24%. Blood chemistry showed a normal white cell count and reduced CRP . The patient underwent bronchoscopy and the bronchial lavage fluid (BLF) revealed a galactomannan level of 3.7 (upper normal limit: 0.5). Total serum immunoglobulin E (IgE) levels were raised (1016 IU ml−1; normal: < 100 IU ml−1), although IgE specific for A. fumigatus was negative, while IgG specific for A. fumigatus was also high . Spirometry showed an obstructive ventilatory pattern, reversible after salbutamol administration, confirming a diagnosis of asthma. Forced vital capacity (FVC) was 3.22 l (70% of predicted) and a forced expiratory volume in 1 s (FEV1) was 2.23 l (61% of predicted) and 3.00 l (+ 34.4%) after bronchodilatation. BLF culture was positive for Pseudomonas aeruginosa rugosa and Achromobacter xylosoxidans. Finally, the following criteria for diagnosis of ABPA were satisfied: (1) predisposing condition as bronchial asthma; (2) elevated total IgE levels (> 1000 IU ml−1); (3) serum IgG antibodies against A. fumigatus; (4) radiographic pulmonary opacities consistent with ABPA. Immediate cutaneous hypersensitivity to Aspergillus antigen was not performed because the patient was on systemic antihistamines. The patient was started on prednisolone (0.5 mg/kg/day) for four weeks. To reduce the antigen burden, oral isavuconazole therapy was also started with a loading dose of 200 mg tid for the first three days and then 200 mg once a day for eight weeks. He was discharged two months after the hospital admission with improved clinical conditions, without oxygen therapy and with reduced total serum IgE levels of 306 IU ml−1. The patient continued steroids, which were gradually tapered down every two weeks. Three months after hospital admission, the patient was seen in our outpatient clinic and he referred only to mild dyspnea during physical exercise. HRCT of the chest showed significant reduction of the multiple nodular opacities and a lung pattern that had almost returned to normal appearance. Total IgE levels were 335 IUml−1. Prednisolone was also tapered, and it is still ongoing at the time of this case presentation at 10 mg daily.", + "fulltext_subclaims": [ + "A 55-year-old Caucasian man presented to the emergency department in April 2020.", + "He had a history of ischemic heart disease, diabetes, arterial hypertension, severe obesity, asthma, and was a smoker.", + "He had fever up to 38.6 °C, cough, and shortness of breath.", + "Oxygen therapy was administered via a Venturi mask at 35%.", + "Blood chemistry revealed a high white cell count.", + "Blood chemistry revealed high levels of C-reactive protein.", + "Blood chemistry revealed a D-dimer level of 1652 mcg/l.", + "Two consecutive nasopharyngeal swabs were negative for SARS-CoV-2.", + "HRCT showed multiple small hazy nodular opacities diffusely distributed throughout both lung fields.", + "The nodules had a centrilobular, linear branching pattern and a 'tree-in-bud' appearance.", + "The HRCT findings were not considered indicative of COVID-19 pneumonia.", + "A possible diagnosis of miliary tuberculosis or other diffuse infectious/inflammatory disease was made.", + "The patient reported living in a damp basement for six weeks before symptom onset.", + "Sputum was negative for acid-fast bacilli in three specimens.", + "Mantoux and QuantiFERON tests were negative.", + "An antibiotic therapy course was started with ceftriaxone 2 g a day and azithromycin 500 mg once a day for seven days.", + "Three weeks after admission, the patient repeated a non-enhanced chest CT scan that showed persistence of the pattern described above.", + "The patient’s clinical condition slightly improved.", + "Oxygen therapy via Venturi mask was reduced to 24%.", + "Blood chemistry showed a normal white cell count and reduced CRP.", + "Bronchial lavage fluid revealed a galactomannan level of 3.7.", + "Total serum immunoglobulin E (IgE) levels were raised (1016 IU ml−1).", + "IgE specific for A. fumigatus was negative.", + "IgG specific for A. fumigatus was also high.", + "Spirometry showed an obstructive ventilatory pattern, reversible after salbutamol administration.", + "The patient was started on prednisolone (0.5 mg/kg/day) for four weeks.", + "Oral isavuconazole therapy was started with a loading dose of 200 mg tid for the first three days and then 200 mg once a day for eight weeks.", + "The patient was discharged two months after hospital admission.", + "Three months after hospital admission, the patient was seen in the outpatient clinic.", + "HRCT showed significant reduction of the multiple nodular opacities.", + "Total IgE levels were 335 IUml−1.", + "Prednisolone was tapered and is still ongoing at the time of this case presentation at 10 mg daily." + ], + "summary": "This case report describes an uncommon but important presentation of allergic bronchopulmonary aspergillosis (ABPA) in a previously healthy male, who decided to live in the basement of his house when Italy entered a nationwide lockdown during the COVID-19 pandemic. As high resolution computed tomography (HRCT) of the chest on admission showed diffuse miliary nodules, a miliary tuberculosis was initially suspected. However, further investigations provided a diagnosis of unusual presentation of ABPA.", + "summary_subclaims": [ + "This case report describes an uncommon but important presentation of allergic bronchopulmonary aspergillosis (ABPA) in a previously healthy male.", + "The patient decided to live in the basement of his house when Italy entered a nationwide lockdown during the COVID-19 pandemic.", + "High resolution computed tomography (HRCT) of the chest on admission showed diffuse miliary nodules.", + "A miliary tuberculosis was initially suspected.", + "Further investigations provided a diagnosis of unusual presentation of ABPA." + ] + }, + { + "id": "multiclinsum_test_2361_en.txt", + "fulltext": "A 43-year-old Sinhalese woman with a history of anovulatory subfertility for 5 years presented to the gynecology clinic of the University Hospital – General Sir John Kotelawala Defence University complaining of heavy menstrual bleeding and secondary dysmenorrhea of 6 months’ duration. She had undergone treatment with clomiphene citrate for eight cycles. Previous imaging did not reveal an ovarian cyst. Her CA 125 had not been measured previously. She had no loss of appetite or loss of weight. Her past medical and psychosocial history was unremarkable. She had no family history of malignancy. On examination, she was afebrile and had a soft abdomen. Her cervix appeared normal upon speculum examination. Bimanual examination revealed that her uterus was of normal size and retroverted. She had a solid nontender adnexal mass extending from the left adnexa to the pouch of Douglas.\nImaging (pelvic ultrasound and computed tomography of her abdomen and pelvis) revealed a hemorrhagic cyst (6 × 4 cm) on the right side and a multilocular cyst with solid areas (10 × 7 cm) on the left side. No peritoneal deposits and ascites were observed. The patient’s CA 125 level was 2715 U/ml. The case was discussed at a multidisciplinary team (MDT) meeting due to the patient’s history of subfertility and elevated CA 125 level.\nA fertility-sparing staging laparotomy was performed, which included right cystectomy, left oophorectomy, infracolic omentectomy, and peritoneal washings. Histology revealed a mucinous cystadenoma on the right ovary and a mature cystic teratoma on the left ovary . No malignant cells were observed in peritoneal washings. Following surgery, the patient’s CA 125 level dropped to 74.8 U/ml 1 month after surgery. She is currently being seen in follow-up and is receiving letrozole for ovulation induction. A timeline of events is shown in Fig. .", + "fulltext_subclaims": [ + "The patient is a 43-year-old Sinhalese woman.", + "She has a history of anovulatory subfertility for 5 years.", + "She presented with heavy menstrual bleeding and secondary dysmenorrhea of 6 months’ duration.", + "She had undergone treatment with clomiphene citrate for eight cycles.", + "Previous imaging did not reveal an ovarian cyst.", + "Her CA 125 had not been measured previously.", + "She had no loss of appetite or loss of weight.", + "Her past medical and psychosocial history was unremarkable.", + "She had no family history of malignancy.", + "On examination, she was afebrile and had a soft abdomen.", + "Her cervix appeared normal upon speculum examination.", + "Bimanual examination revealed that her uterus was of normal size and retroverted.", + "She had a solid nontender adnexal mass extending from the left adnexa to the pouch of Douglas.", + "Imaging revealed a hemorrhagic cyst (6 × 4 cm) on the right side.", + "Imaging revealed a multilocular cyst with solid areas (10 × 7 cm) on the left side.", + "No peritoneal deposits and ascites were observed.", + "The patient’s CA 125 level was 2715 U/ml.", + "The case was discussed at a multidisciplinary team meeting.", + "A fertility-sparing staging laparotomy was performed.", + "The laparotomy included right cystectomy, left oophorectomy, infracolic omentectomy, and peritoneal washings.", + "Histology revealed a mucinous cystadenoma on the right ovary.", + "Histology revealed a mature cystic teratoma on the left ovary.", + "No malignant cells were observed in peritoneal washings.", + "Following surgery, the patient’s CA 125 level dropped to 74.8 U/ml 1 month after surgery.", + "She is currently being seen in follow-up.", + "She is receiving letrozole for ovulation induction." + ], + "summary": "A 43-year-old Sinhalese woman with a history of anovulatory subfertility for 5 years presented with heavy menstrual bleeding and secondary dysmenorrhea of 6 months' duration. Imaging (pelvic ultrasound and computed tomography of the abdomen and pelvis) revealed a hemorrhagic cyst (6 × 4 cm) on the right side and a multilocular cyst with solid areas (10 × 7 cm) on the left side. Her cancer antigen 125 level was 2715 U/ml. Following a multidisciplinary team meeting, a fertility-sparing staging laparotomy was performed, which included right cystectomy, left oophorectomy, infracolic omentectomy, and peritoneal washings. Histology revealed a mucinous cystadenoma of the right ovary and a mature cystic teratoma on the left ovary. No malignant cells were observed in peritoneal washings. The patient's cancer antigen 125 level dropped to 74.8 U/ml 1 month after surgery.", + "summary_subclaims": [ + "The patient is a 43-year-old Sinhalese woman.", + "She has a history of anovulatory subfertility for 5 years.", + "She presented with heavy menstrual bleeding.", + "She had secondary dysmenorrhea of 6 months' duration.", + "Imaging revealed a hemorrhagic cyst on the right side.", + "The hemorrhagic cyst measured 6 × 4 cm.", + "Imaging revealed a multilocular cyst with solid areas on the left side.", + "The multilocular cyst measured 10 × 7 cm.", + "Her cancer antigen 125 level was 2715 U/ml.", + "A fertility-sparing staging laparotomy was performed.", + "Right cystectomy was performed.", + "Left oophorectomy was performed.", + "Infracolic omentectomy was performed.", + "Peritoneal washings were obtained.", + "Histology revealed a mucinous cystadenoma of the right ovary.", + "Histology revealed a mature cystic teratoma on the left ovary.", + "No malignant cells were observed in peritoneal washings.", + "The patient's cancer antigen 125 level dropped to 74.8 U/ml 1 month after surgery." + ] + }, + { + "id": "multiclinsum_test_787_en.txt", + "fulltext": "A 51-year-old Caucasian woman presented to the outpatient clinic with spinal, pelvic, and sternal inflammatory pain lasting for many years. The symptoms had a strong negative impact on her quality of life. She did not present palmoplantar pustulosis. There was no context of fever.\nShe had been diagnosed with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome at the age of 40 years. She had received sulfasalazine and nonsteroidal anti-inflammatory drugs (NSAIDs) for many years with incomplete pain relief.\nShe also had a history of cervical and lumbar arthrodesis, hypertension, and thyroidectomy.\nTotal spine and pelvis magnetic resonance imaging (MRI) showed a short tau inversion recovery (STIR) hypersignal on several thoracic vertebrae (T6, T7, T8, and T9) and on the sternal part of the right clavicle. Bone marrow oedema was also found on the right iliac bone, though the sacroiliac joints were preserved . Bone scintigraphy showed anterior chest wall involvement with right sternoclavicular hyperostosis on computed tomography.\nThe C-reactive protein (CRP) was found to be 89.2 mg/L (reference range, 0–5 mg/L). Several blood tests performed earlier had already shown elevation of inflammation parameters. HLA B27 antigen was negative.\nWe confirmed the diagnosis of active SAPHO syndrome.\nWe did not consider administering conventional synthetic disease-modifying antirheumatic drug (csDMARD) as methotrexate, which is more effective on peripheral arthritis. Indeed, methotrexate has not shown comparable activity in axial disease in patients with axial spondyloarthritis.\nMoreover, we could not prescribe anti-tumour necrosis factor (TNF) drugs because the criteria for reimbursement of these drugs in Belgium were not met in the absence of sacroiliitis.\nGiven some encouraging results reported with JAK-inhibitors in the literature [, ], we initiated tofacitinib 5 mg twice daily.\nThe patient reported rapid and significant reduction of pain within weeks of starting the treatment.\nBlood tests performed one month after the onset of treatment showed a clear regression of inflammatory parameters, with a CRP at 25.5 mg/L (reference range, 0–5 mg/L), followed by 14 mg/L and 9.9 mg/L after 4 and 10 months of treatment, respectively .\nTotal spine and pelvis MRI performed after 3 months of treatment showed regression of the STIR hypersignal on the body of the thoracic vertebrae, as well as the disappearance of the hypersignal of the right iliac bone .\nWe could therefore conclude that the rheumatic evolution was favourable from a clinical, biological, and radiological point of view since the introduction of a JAK-inhibitor.\nUnfortunately, the treatment had to be discontinued due to pulmonary embolism occurring after 8 months on tofacitinib.\nGradually, spinal, pelvic, and chest (sternal and costal) pain reappeared along with the elevation of inflammatory parameters.\nWritten informed consent was obtained from the patient for the publication of this report and its accompanying images.", + "fulltext_subclaims": [ + "The patient is a 51-year-old Caucasian woman.", + "She presented with spinal, pelvic, and sternal inflammatory pain lasting for many years.", + "The symptoms had a strong negative impact on her quality of life.", + "She did not present palmoplantar pustulosis.", + "There was no context of fever.", + "She had been diagnosed with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome at the age of 40 years.", + "She had received sulfasalazine and nonsteroidal anti-inflammatory drugs (NSAIDs) for many years with incomplete pain relief.", + "She also had a history of cervical and lumbar arthrodesis.", + "She had a history of hypertension.", + "She had a history of thyroidectomy.", + "Total spine and pelvis magnetic resonance imaging (MRI) showed a short tau inversion recovery (STIR) hypersignal on several thoracic vertebrae (T6, T7, T8, and T9).", + "Total spine and pelvis MRI showed a short tau inversion recovery (STIR) hypersignal on the sternal part of the right clavicle.", + "Bone marrow oedema was also found on the right iliac bone.", + "The sacroiliac joints were preserved.", + "Bone scintigraphy showed anterior chest wall involvement.", + "Right sternoclavicular hyperostosis was found on computed tomography.", + "The C-reactive protein (CRP) was found to be 89.2 mg/L.", + "The reference range for CRP is 0–5 mg/L.", + "Several blood tests performed earlier had already shown elevation of inflammation parameters.", + "HLA B27 antigen was negative.", + "The diagnosis of active SAPHO syndrome was confirmed.", + "Conventional synthetic disease-modifying antirheumatic drug (csDMARD) as methotrexate was not considered.", + "Methotrexate is more effective on peripheral arthritis.", + "Methotrexate has not shown comparable activity in axial disease in patients with axial spondyloarthritis.", + "Anti-tumour necrosis factor (TNF) drugs could not be prescribed because the criteria for reimbursement of these drugs in Belgium were not met.", + "The criteria for reimbursement were not met in the absence of sacroiliitis.", + "JAK-inhibitors were initiated.", + "Tofacitinib 5 mg twice daily was initiated.", + "The patient reported rapid and significant reduction of pain within weeks of starting the treatment.", + "Blood tests performed one month after the onset of treatment showed a clear regression of inflammatory parameters.", + "The CRP was 25.5 mg/L one month after the onset of treatment.", + "The CRP was 14 mg/L after 4 months of treatment.", + "The CRP was 9.9 mg/L after 10 months of treatment.", + "Total spine and pelvis MRI performed after 3 months of treatment showed regression of the STIR hypersignal on the body of the thoracic vertebrae.", + "The hypersignal of the right iliac bone disappeared after 3 months of treatment.", + "The rheumatic evolution was favourable from a clinical, biological, and radiological point of view since the introduction of a JAK-inhibitor.", + "The treatment had to be discontinued due to pulmonary embolism occurring after 8 months on tofacitinib.", + "Spinal, pelvic, and chest (sternal and costal) pain reappeared after discontinuation of tofacitinib.", + "Elevation of inflammatory parameters occurred after discontinuation of tofacitinib.", + "Written informed consent was obtained from the patient for the publication of this report and its accompanying images." + ], + "summary": "We report the case of a 51-year-old Caucasian woman who presented with SAPHO syndrome with mainly axial involvement. She had been treated with sulfasalazine and anti-inflammatory drugs for many years without any success. A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved. Imaging also showed considerable regression of the vertebral and pelvic lesions. However, tofacitinib had to be discontinued due to the occurrence of pulmonary embolism. Consequently, recurrence of bone pain and biologic inflammation was rapidly observed.", + "summary_subclaims": [ + "The patient was a 51-year-old Caucasian woman.", + "She had SAPHO syndrome with mainly axial involvement.", + "She had been treated with sulfasalazine and anti-inflammatory drugs for many years.", + "The treatment with sulfasalazine and anti-inflammatory drugs was without any success.", + "A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved.", + "Imaging showed considerable regression of the vertebral and pelvic lesions.", + "Tofacitinib had to be discontinued due to the occurrence of pulmonary embolism.", + "Recurrence of bone pain and biologic inflammation was rapidly observed." + ] + }, + { + "id": "multiclinsum_test_2547_en.txt", + "fulltext": "A 68-year-old male patient, a former farm laborer, presented with low-back pain that had started four months earlier. Over the preceding two years, he had had three episodes of pneumonia and lost 20 kg. He had systemic arterial hypertension, which was controlled through use of antihypertensive drugs. There was no diabetes, thyroid diseases or any other metabolic cause for weight loss. He was a smoker (50 pack-years) and moderate alcohol user.\nThe symptoms became worse during trunk flexion and there was painful low-back muscle palpation. There were no abnormalities on neurological examination, no fever and no night pain. No signs of consumptive syndrome were noted.\nLaboratory tests revealed increased levels of C-reactive protein (CRP) of 118.5 mg/dl (normal, 0.05 mg/dl) and erythrocyte sedimentation rate (ESR) of 53 mm/h (normal < 15 mm/h). The white blood cell count was 6-7 k/mm3 (normal, 4.0-11.0 k/mm3). A sputum culture was negative for tuberculosis. Chest radiography and computed tomography (CT) scan did not reveal any signs of tumor or infection.\nRadiography of the lumbosacral spine showed diffuse degenerative changes, irregular vertebral endplates of L4 and L5, and reduction of disc spaces L4-L5 and L5-S1 .\nLumbar spine magnetic resonance imaging (MRI) demonstrated spondylodiscitis of L4-L5, with subligamentous abscess anterior to the vertebral bodies, reduced disc height of L4-L5 and L5-S1 and spinal stenosis from L2 to S1 ( and ).\nAfter analyzing MRI data, main hypotheses for this case were the presence of a tumor, tuberculosis or pyogenic spondylodiscitis. However, transpedicular biopsy of L4 revealed infection with Paracoccidioides brasiliensis .\nSince the patient was not presenting any mechanical or neurological instability, clinical treatment was implemented. Therapy with itraconazole (200 mg/day) was started, but the patient presented an adverse reaction to this drug (worsening of liver function), and therefore this was replaced with sulfamethoxazole and trimethoprim (20 mg/kg) for the rest of the treatment. After 36 months of treatment with sulfamethoxazole and trimethoprim (20 mg/kg), the patient became asymptomatic and the inflammatory blood tests (CRP and ESR) returned to normal.\nA control radiograph showed ligament ossification of L4-L5, subchondral sclerosis and reduction of disc space. Control MRI demonstrated reduction of edema and abscess in the paraspinal soft tissues .", + "fulltext_subclaims": [ + "The patient is a 68-year-old male.", + "He is a former farm laborer.", + "He had low-back pain that started four months earlier.", + "He had three episodes of pneumonia over the preceding two years.", + "He lost 20 kg.", + "He had systemic arterial hypertension controlled by antihypertensive drugs.", + "There was no diabetes.", + "There was no thyroid disease.", + "There was no other metabolic cause for weight loss.", + "He was a smoker with 50 pack-years.", + "He was a moderate alcohol user.", + "The symptoms became worse during trunk flexion.", + "There was painful low-back muscle palpation.", + "There were no abnormalities on neurological examination.", + "There was no fever.", + "There was no night pain.", + "No signs of consumptive syndrome were noted.", + "C-reactive protein (CRP) was 118.5 mg/dl.", + "Erythrocyte sedimentation rate (ESR) was 53 mm/h.", + "White blood cell count was 6-7 k/mm3.", + "Sputum culture was negative for tuberculosis.", + "Chest radiography did not reveal any signs of tumor or infection.", + "Computed tomography (CT) scan did not reveal any signs of tumor or infection.", + "Radiography of the lumbosacral spine showed diffuse degenerative changes.", + "Radiography showed irregular vertebral endplates of L4 and L5.", + "Radiography showed reduction of disc spaces L4-L5 and L5-S1.", + "MRI demonstrated spondylodiscitis of L4-L5.", + "MRI showed subligamentous abscess anterior to the vertebral bodies.", + "MRI showed reduced disc height of L4-L5 and L5-S1.", + "MRI showed spinal stenosis from L2 to S1.", + "Main hypotheses were tumor, tuberculosis, or pyogenic spondylodiscitis.", + "Transpedicular biopsy of L4 revealed infection with Paracoccidioides brasiliensis.", + "The patient was not presenting mechanical or neurological instability.", + "Clinical treatment was implemented.", + "Therapy with itraconazole (200 mg/day) was started.", + "The patient presented an adverse reaction to itraconazole.", + "Itraconazole was replaced with sulfamethoxazole and trimethoprim (20 mg/kg).", + "After 36 months of treatment with sulfamethoxazole and trimethoprim, the patient became asymptomatic.", + "Inflammatory blood tests returned to normal.", + "Control radiograph showed ligament ossification of L4-L5.", + "Control radiograph showed subchondral sclerosis.", + "Control radiograph showed reduction of disc space.", + "Control MRI demonstrated reduction of edema.", + "Control MRI demonstrated reduction of abscess in the paraspinal soft tissues." + ], + "summary": "We describe a case of a 68-year-old male patient with spondylodiscitis at the levels L4-L5 caused by presence of the fungus Paracoccidioides brasiliensis, which was diagnosed through percutaneous biopsy. The patient was treated with sulfamethoxazole and trimethoprim for 36 months, with complete resolution of the symptoms.", + "summary_subclaims": [ + "The patient was a 68-year-old male.", + "The patient had spondylodiscitis at the levels L4-L5.", + "The spondylodiscitis was caused by the fungus Paracoccidioides brasiliensis.", + "The diagnosis was made through percutaneous biopsy.", + "The patient was treated with sulfamethoxazole and trimethoprim.", + "The treatment duration was 36 months.", + "The patient had complete resolution of the symptoms." + ] + }, + { + "id": "multiclinsum_test_2864_en.txt", + "fulltext": "A 56-year-old male patient with end-stage ischaemic cardiomyopathy, chronic kidney disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and dyslipidaemia developed cerebral infarction due to thrombosis of the right medial cerebral artery approximately one and a half year after minimally invasive left ventricular assist device (LVAD) implantation (HeartWare HVAD®, Medtronic plc, Dublin, Ireland). The patient successfully underwent mechanical thrombectomy and was listed for HTx with high urgency waiting list status. Another 43 days later, the patient was finally allocated to a suitable donor organ of a 22-year-old donor and underwent HTx in orthotopic bicaval technic. Although reported donor ejection fraction was good (>60%) and transport time (157 min) and warm ischaemia (49 min) were not prolonged, the patient developed immediately PGD with biventricular failure and severe impairment of left ventricular function (ejection fraction < 20%). After a total reperfusion time of more than 150 min, we decided to implant a microaxial pump (Impella 5.0®, Abiomed, Inc., Danvers, MA, USA) via a vascular prosthesis connected to the right subclavian artery for temporary isolated left ventricular mechanically assistance. However, due to concomitant right heart failure, additional right ventricular assistance was inevitable. Thus, we upgraded the running Impella® system to ECMELLA configuration by additional VA-ECMO implantation via a second arm of the already implanted vascular prosthesis of the right subclavian artery and the right femoral vein as described before by Eulert-Grehn et al. Afterwards, the patient was stabilized and transferred to the intensive care unit.\nIn the following, the patient developed progressive hyperaemia of the right arm with consecutive therapy-refractory lactataemia. At the first postoperative day, we therefore switched the arterial cannula of the VA-ECMO to the right femoral artery. Unfortunately, the patient suffered from multiple bleeding complications during ECMELLA support with need for a total of four thoracic revisions and temporary thorax apertum due to repetitive haematothoraces. Finally, ventricular function recovered after levosimendan therapy and the Impella® device was explanted eight days after HTx. Due to on-going right ventricular dysfunction, we maintained VA-ECMO support for additional 4 days. We explanted VA-ECMO on the 15th postoperative day achieving thoracic occlusion. A detailed timeline of all operative procedures is displayed in .\nApproximately one month after the HTx, the patient was transferred to the intermediate care unit and at the 46th postoperative day, the patient was finally discharged to a rehabilitation clinic. At discharge, echocardiography confirmed full biventricular recovery with left ventricular ejection fraction at 53% and apparently good right ventricular function without any valve pathologies.\nAt follow-up, two months following HTx the patient presented fully recovered without any heart failure symptoms or chronic kidney injury. He reported regular physical exercise without any dyspnoea and echocardiography revealed normal cardiac function.", + "fulltext_subclaims": [ + "The patient is a 56-year-old male.", + "The patient has end-stage ischaemic cardiomyopathy.", + "The patient has chronic kidney disease.", + "The patient has chronic obstructive pulmonary disease.", + "The patient has type 2 diabetes mellitus.", + "The patient has dyslipidaemia.", + "The patient developed cerebral infarction due to thrombosis of the right medial cerebral artery.", + "The cerebral infarction occurred approximately one and a half year after minimally invasive LVAD implantation.", + "The LVAD implanted was a HeartWare HVAD®.", + "The patient successfully underwent mechanical thrombectomy.", + "The patient was listed for HTx with high urgency waiting list status.", + "The patient was allocated to a suitable donor organ 43 days after being listed.", + "The donor was 22 years old.", + "The HTx was performed in orthotopic bicaval technic.", + "The reported donor ejection fraction was >60%.", + "The transport time was 157 minutes.", + "The warm ischaemia time was 49 minutes.", + "The patient developed immediately PGD with biventricular failure.", + "The patient had severe impairment of left ventricular function with ejection fraction < 20%.", + "A microaxial pump (Impella 5.0®) was implanted via a vascular prosthesis connected to the right subclavian artery.", + "The Impella® system was upgraded to ECMELLA configuration by additional VA-ECMO implantation.", + "The VA-ECMO arterial cannula was switched to the right femoral artery.", + "The patient suffered multiple bleeding complications during ECMELLA support.", + "The patient required four thoracic revisions.", + "The Impella® device was explanted eight days after HTx.", + "VA-ECMO support was maintained for additional 4 days due to ongoing right ventricular dysfunction.", + "VA-ECMO was explanted on the 15th postoperative day.", + "The patient was transferred to the intermediate care unit approximately one month after HTx.", + "The patient was discharged to a rehabilitation clinic on the 46th postoperative day.", + "Echocardiography at discharge confirmed full biventricular recovery.", + "The left ventricular ejection fraction at discharge was 53%.", + "The patient reported regular physical exercise without dyspnoea at follow-up.", + "Echocardiography at follow-up revealed normal cardiac function.", + "The patient was fully recovered without heart failure symptoms at follow-up." + ], + "summary": "Here, we report a case of a 56-year-old patient suffering from severe PGD after HTx with biventricular failure (ejection fraction < 20%) who was successfully bridged to recovery of the donor graft by temporary multimodal mechanically circulatory assistance by combining both, VA-ECMO and a microaxial pump (Impella®, Abiomed, Inc., Danvers, MA, USA), a concept also referred as ECMELLA. During ECMELLA support, the patient experienced multiple severe thoracic bleeding complications with need for four re-thoracotomies and temporary open chest situation. Nevertheless, ventricular function recovered and the patient could be weaned from mechanical circulatory support after 12 days. During follow-up, the patient recovered and was successfully discharged. After the following rehabilitation, the patient now shows no persistent signs of heart failure with normal biventricular function of the cardiac graft.", + "summary_subclaims": [ + "The patient was a 56-year-old individual.", + "The patient suffered from severe PGD after HTx.", + "The patient had biventricular failure with ejection fraction < 20%.", + "The patient was successfully bridged to recovery of the donor graft.", + "The patient received temporary multimodal mechanical circulatory assistance.", + "The assistance combined VA-ECMO and a microaxial pump (Impella®).", + "This concept is referred to as ECMELLA.", + "During ECMELLA support, the patient experienced multiple severe thoracic bleeding complications.", + "The patient required four re-thoracotomies.", + "The patient had a temporary open chest situation.", + "Ventricular function recovered.", + "The patient was weaned from mechanical circulatory support after 12 days.", + "The patient was successfully discharged.", + "After rehabilitation, the patient shows no persistent signs of heart failure.", + "The patient now has normal biventricular function of the cardiac graft." + ] + }, + { + "id": "multiclinsum_test_1123_en.txt", + "fulltext": "A 21-year-old Caucasian woman presented to an outside facility with altered mental status after being found lethargic by family. On arrival to the emergency department, plasma glucose was 20 mg/dl. The patient was hospitalized and started on dextrose infusion, including 10% dextrose in water but remained hypoglycemic with capillary glucose ranging between 50 and 60 mg/dl. She was transferred to our facility on suspicion of an insulinoma as the patient was unable to recall her prior diagnosis.\nMedical records from our hospital revealed treatment for hypoglycemia as a neonate. The patient reported repeated episodes of seizures, syncope, dizziness, headaches, palpitations, and sweating around age 12; however, symptoms were never formally investigated as she did not seek expert care. These symptoms were also reported to have been present since birth but had been intermittent and of varying severity. She remained seizure-free and without syncopal episodes until 17 when she experienced another syncopal episode. At that time, she underwent extensive inpatient hypoglycemia evaluation with the following results: blood glucose of 47 mg/dl after 2 h of fasting, proinsulin levels varying from 10.4 to 84.1 pmol/l (normal range 0–10 pmol/l), C-peptide level 3.1 ng/ml (normal range 1.1–4.4 ng/ml), negative insulin antibodies and sulfonylurea screen. Magnetic resonance imaging of the abdomen showed no insulinoma, but genetic studies revealed Val452 Leu activating mutation of the GCK gene. She was successfully treated with diazoxide and discharged home on oral diazoxide 250 mg daily, which she discontinued due to side effects of hirsutism and fluid retention.\nOn current admission, the patient was treated with dextrose boluses initially. Her blood glucose level remained low in spite of a continuous infusion of 5% dextrose necessitating transfer to an intensive care unit. Both fasting and postprandial blood glucose levels were low. As review of her medication list did not show any implicating drugs, no additional work-up was pursued. She was then placed on octreotide 200 µg subcutaneously twice daily and diazoxide suspension 100 mg three times a day on consultation with the pediatric endocrinologist. Neuroglycopenic symptoms of hypoglycemia improved. The patient's hypoglycemia improved with capillary glucose of 55–110 mg/dl by the time of discharge. Importance of compliance with the treatment and follow-up with an endocrinologist was emphasized.", + "fulltext_subclaims": [ + "The patient is a 21-year-old Caucasian woman.", + "She presented with altered mental status.", + "On arrival to the emergency department, plasma glucose was 20 mg/dl.", + "The patient was hospitalized and started on dextrose infusion.", + "The dextrose infusion included 10% dextrose in water.", + "She remained hypoglycemic with capillary glucose ranging between 50 and 60 mg/dl.", + "She was transferred to our facility on suspicion of an insulinoma.", + "The patient was unable to recall her prior diagnosis.", + "Medical records from our hospital revealed treatment for hypoglycemia as a neonate.", + "The patient reported repeated episodes of seizures, syncope, dizziness, headaches, palpitations, and sweating around age 12.", + "These symptoms were never formally investigated as she did not seek expert care.", + "She remained seizure-free and without syncopal episodes until 17.", + "At age 17, she experienced another syncopal episode.", + "At that time, she underwent extensive inpatient hypoglycemia evaluation.", + "Blood glucose was 47 mg/dl after 2 h of fasting.", + "Proinsulin levels varied from 10.4 to 84.1 pmol/l.", + "C-peptide level was 3.1 ng/ml.", + "Magnetic resonance imaging of the abdomen showed no insulinoma.", + "Genetic studies revealed Val452 Leu activating mutation of the GCK gene.", + "She was successfully treated with diazoxide.", + "She was discharged home on oral diazoxide 250 mg daily.", + "She discontinued diazoxide due to side effects of hirsutism and fluid retention.", + "On current admission, the patient was treated with dextrose boluses initially.", + "Her blood glucose level remained low in spite of a continuous infusion of 5% dextrose.", + "This necessitated transfer to an intensive care unit.", + "Both fasting and postprandial blood glucose levels were low.", + "Review of her medication list did not show any implicating drugs.", + "No additional work-up was pursued.", + "She was placed on octreotide 200 µg subcutaneously twice daily.", + "She was placed on diazoxide suspension 100 mg three times a day.", + "This was done on consultation with the pediatric endocrinologist.", + "Neuroglycopenic symptoms of hypoglycemia improved.", + "The patient's hypoglycemia improved with capillary glucose of 55–110 mg/dl by the time of discharge.", + "Importance of compliance with the treatment was emphasized.", + "Importance of follow-up with an endocrinologist was emphasized." + ], + "summary": "A 21-year-old obese woman presented to the emergency department with complaints of repeated episodes of lethargy, syncope, dizziness, and sweating. She was referred from an outside facility on suspicion of insulinoma, with severe hypoglycemia unresponsive to repeated dextrose infusions. Her plasma glucose was 20 mg/dl at presentation, 44 mg/dl on arrival at our facility, and remained low in spite of multiple dextrose infusions. The patient had been treated for persistent hyperinsulinemic hypoglycemia of infancy at our neonatal facility and 4 years ago was diagnosed as having an activating glucokinase (GCK) mutation. She was then treated with octreotide and diazoxide with improvement in symptoms and blood glucose levels.", + "summary_subclaims": [ + "The patient is a 21-year-old obese woman.", + "She presented to the emergency department with repeated episodes of lethargy.", + "She presented to the emergency department with repeated episodes of syncope.", + "She presented to the emergency department with repeated episodes of dizziness.", + "She presented to the emergency department with repeated episodes of sweating.", + "She was referred from an outside facility on suspicion of insulinoma.", + "She had severe hypoglycemia unresponsive to repeated dextrose infusions.", + "Her plasma glucose was 20 mg/dl at presentation.", + "Her plasma glucose was 44 mg/dl on arrival at our facility.", + "Her plasma glucose remained low in spite of multiple dextrose infusions.", + "The patient had been treated for persistent hyperinsulinemic hypoglycemia of infancy at our neonatal facility.", + "She was diagnosed as having an activating glucokinase (GCK) mutation 4 years ago.", + "She was treated with octreotide.", + "She was treated with diazoxide.", + "She had improvement in symptoms.", + "She had improvement in blood glucose levels." + ] + }, + { + "id": "multiclinsum_test_1010_en.txt", + "fulltext": "A 49-year-old woman at first consultation presented at our hospital for surveillance of the pancreas because her father (II-3) and her younger brother (III-6) had pancreatic cancer. She had undergone surgery for subarachnoid hemorrhage at 19 years of age because of an arteriovenous malformation. Her family tree revealed that her younger brother died of pancreatic cancer at 33 years of age; he could not be treated through surgery because of his advanced stage with distant metastasis. The patient’s paternal aunt (II-1) also died of pancreatic cancer at 65 years of age. Her father was also diagnosed with advanced-stage pancreatic cancer, which could not be controlled despite chemotherapy.\nIn the first genetic counseling session, the patient was informed that she was likely to have FPC, Lynch syndrome, or HBOC syndrome, all of which follow an autosomal dominant inheritance pattern. Therefore, germline multi-gene panel testing using ACTRisk® (ACT Genomics, Co. Ltd. Taipei, Taiwan) was performed to analyze germline variants in this case.\nIn the second genetic counseling session, we informed her that the blood genetic test revealed two germline variants. She harbored a heterozygous PALB2 pathogenic variant, NM_024675(PALB2): c.1675_1676inv (p.Gln559*), and a heterozygous NBN pathogenic variant, NM_002485(NBN): c.265C > T (p.Arg89*). These variants are predicted to cause loss of normal protein function through either protein truncation or nonsense-mediated mRNA decay. Therefore, we advised her to undergo surveillance for breast, ovarian, and pancreatic cancer. Her father died 9 months after her first consultation; however, he had previously provided a blood sample to our department before his death to support her future healthcare. Accordingly, genetic testing of her father’s blood sample was recommended to her.\nIn the third genetic counseling session, we explained that her father’s blood revealed the presence of the PALB2 c.1675_1676inv (p.Gln559) pathogenic variant, which was the same as hers. Furthermore, we informed her that her first-degree relatives (FDR) have a 50% chance of testing positive for these variants. Therefore, we recommended genetic counseling for her children at the next session, and she agreed.\nIn the fourth genetic counseling session, the patient and her three children, a 28-year-old woman, a 24-year-old man, and a 22-year-old man, presented at our outpatient department. We explained to them that their mother and her father harbored the PALB2 pathogenic variant, which was probably associated with breast, ovarian, pancreatic, and prostate cancer. Furthermore, we informed them that their mother harbored the NBN pathogenic variant, which was potentially associated with breast, ovarian, and pancreatic cancer. Upon surveillance, no issue was noted in the cases’s breasts and ovaries; however, she displayed a branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) in her pancreas. We suggested she continue active surveillance of her breasts, ovaries, and pancreas. Furthermore, her 28-year-old daughter wished to undergo genetic testing because her uncle had died from pancreatic cancer at an early age. Therefore, we performed genetic testing at a single site for the patient’s daughter. Finally, the patient’s daughter underwent genetic counseling and was found to harbor only the NBN c.265C > T(p.Arg89*) pathogenic variant, which was probably associated with breast, ovarian, pancreatic cancer. Thus, the daughter will be recommended to undergo surveillance for breast, ovarian, and pancreatic cancer.", + "fulltext_subclaims": [ + "The patient is a 49-year-old woman.", + "The patient presented for surveillance of the pancreas.", + "The patient’s father (II-3) had pancreatic cancer.", + "The patient’s younger brother (III-6) had pancreatic cancer.", + "The patient had undergone surgery for subarachnoid hemorrhage at 19 years of age.", + "The patient’s younger brother died of pancreatic cancer at 33 years of age.", + "The patient’s younger brother could not be treated through surgery because of his advanced stage with distant metastasis.", + "The patient’s paternal aunt (II-1) died of pancreatic cancer at 65 years of age.", + "The patient’s father was diagnosed with advanced-stage pancreatic cancer.", + "The patient’s father’s cancer could not be controlled despite chemotherapy.", + "The patient was informed that she was likely to have FPC, Lynch syndrome, or HBOC syndrome.", + "Germline multi-gene panel testing using ACTRisk® was performed.", + "The blood genetic test revealed two germline variants.", + "The patient harbored a heterozygous PALB2 pathogenic variant, NM_024675(PALB2): c.1675_1676inv (p.Gln559*).", + "The patient harbored a heterozygous NBN pathogenic variant, NM_002485(NBN): c.265C > T (p.Arg89*).", + "These variants are predicted to cause loss of normal protein function.", + "The patient was advised to undergo surveillance for breast, ovarian, and pancreatic cancer.", + "The patient’s father died 9 months after her first consultation.", + "The patient’s father had previously provided a blood sample to the department.", + "Genetic testing of the patient’s father’s blood sample was recommended.", + "The patient’s father’s blood revealed the presence of the PALB2 c.1675_1676inv (p.Gln559) pathogenic variant.", + "The patient’s father’s variant was the same as hers.", + "The patient’s first-degree relatives have a 50% chance of testing positive for these variants.", + "Genetic counseling was recommended for the patient’s children.", + "The patient agreed to genetic counseling for her children.", + "The patient and her three children presented at the outpatient department.", + "The patient’s daughter wished to undergo genetic testing.", + "The patient’s daughter underwent genetic testing at a single site.", + "The patient’s daughter was found to harbor only the NBN c.265C > T(p.Arg89*) pathogenic variant.", + "The daughter will be recommended to undergo surveillance for breast, ovarian, and pancreatic cancer." + ], + "summary": "Here, we present the case of a female patient harboring pathogenic variants of PALB2 and NBN, with a family history of multiple pancreatic cancer in her younger brother, her aunt, and her father. Moreover, her father harbored a PALB2 pathogenic variant and her daughter harbored the same NBN pathogenic variant. Given the PALB2 and NBN variants, we designed surveillance strategies for the pancreas, breast, and ovary.", + "summary_subclaims": [ + "The patient is female.", + "The patient harbors pathogenic variants of PALB2 and NBN.", + "The patient has a family history of multiple pancreatic cancer in her younger brother.", + "The patient has a family history of multiple pancreatic cancer in her aunt.", + "The patient has a family history of multiple pancreatic cancer in her father.", + "The patient's father harbored a PALB2 pathogenic variant.", + "The patient's daughter harbored the same NBN pathogenic variant.", + "Given the PALB2 and NBN variants, we designed surveillance strategies for the pancreas.", + "Given the PALB2 and NBN variants, we designed surveillance strategies for the breast.", + "Given the PALB2 and NBN variants, we designed surveillance strategies for the ovary." + ] + }, + { + "id": "multiclinsum_test_536_en.txt", + "fulltext": "On October 8, 2020, a 52-year-old Chinese female was admitted to a local state hospital with cough and expectoration, and a chest CT scan revealed an oblique fissure effusion in the right lung , which was diagnosed as a pulmonary infection and treated empirically with levofloxacin at the local state hospital. After 1 week of treatment with this regimen, the patient developed shortness of breath, and the supervising physician adjusted the treatment regimen to levofloxacin combined with latamoxef sodium considering poor infection control. After another 1 week of anti-infective treatment, the patient felt that her symptoms were relieved and asked to be discharged from the hospital and stopped taking antibiotics on her own. After discharge, the patient’s shortness of breath gradually worsened, and she went to the local state hospital again on October 31, and a repeat CT scan showed a large thick-walled cavity in the right lung . Outpatient doctors suggested that the patient continue hospitalization. On November 1st, the patient suffered from sudden pain in the right chest and difficulty breathing during hospitalization, so she was transferred to our hospital in the emergency department. She used to have type 2 diabetes without a history of joint pain, heart valvular disease, lung surgery, and no family history of the tumor.\nOnce admitted, the patient underwent re-examination by CT that revealed right hydropneumothorax and extensive compression atelectasis , and then was diagnosed with pyothorax. Moreover, laboratory inspection including WWBC 6.5 × 109/L, PLT 298 × 109/L, IL-6955.2 pg/mL, PCT 0.99 ng/mL, CRP > 90 mg/L, ALB33.02 g/L, indicated infection and malnutrition, and empirical treatment of moxifloxacin were given in the emergency. On November 3, she was admitted to the intensive care unit. The ultrasonic examination showed that the localized anechoic area of 13.0 cm × 10.1 cm × 6.2 cm in the right thoracic cavity and she was given moxifloxacin plus thoracic puncture and drainage. The drainage was porridge-like, with a fishy smell, and the pus was sent for biochemical examination . Dyspnea was improved after drainage of 1300 ml pleural effusion for 2 days.\nOn November 6, she was transferred to the general ward and continued to be treated with broad-spectrum moxifloxacin. At the same time, fibrinolytic drugs were injected into the pleural cavity for 72 h. During the treatment, the symptoms of shortness of breath worsened again, and ultrasound re-examination showed that the localized anechoic area of 12.5c × 6.8 cm × 6.7 cm was in the right thoracic cavity. The drainage device was replaced by closed thoracic drainage and intermittent drainage of 1000 ml pleural effusion. The drainage fluid was sent to 2 groups of blood culture on different days (each group included an aerobic bottle and an anaerobic bottle). The equipment is a two-way blood culture bottle, consisting of peptone, beef paste, and other culture media, which is suitable for in vitro culture and detection of various aerobic or anaerobic bacteria in body fluids (blood, pleural fluid, etc.). The culture results showed that there were 3 strains of G.adiacens, 1 strain of Eikenella corrodens, and 1 strain of Staphylococcus aureus. G.adiacens were identified as the main pathogen due to its high detection rate, and the drug sensitivity test showed that it was sensitive to penicillin, erythromycin, vancomycin, cefotaxime, levofloxacin, and linezolid. According to the results of drug sensitivity, we continued to give moxifloxacin treatment (both moxifloxacin and levofloxacin belong to fluoroquinolone antibiotics, with similar antimicrobial spectra and stronger effect of moxifloxacin on cocci and anaerobic bacteria), and additively covered anaerobic bacteria with ornidazole. We also arranged echocardiography and electronic bronchoscopy for the patient. Echocardiography examination showed local calcification of the aortic valve without valvular insufficiency and vegetation, which ruled out endocardial infection. Bronchoscopy examination showed external compressive stenosis of the right middle bronchus . Besides, minced meat-like tissue of the lower lobe of the right lung was found in the bronchoscopy, and pathological examination revealed adenocarcinoma . On November 18, CT re-examination showed right pleural thickening, pleural effusion, multiple cord shadows in the middle and lower lobe bottom consolidation . After multidisciplinary consultation, it is suggested that surgical intervention should be carried out after the control of pulmonary infection. On November 19, the patient went home with a drainage device and was given oral moxifloxacin and ornidazole as discharge drugs. At the same time, nutritional support lasted throughout the medication period. The patient was revisited On December 7, WBCC and CRP were in the normal range, CT showed right pleural thickening, obvious absorption of multiple cords in the middle and lower lobe of the right lung, and slightly reduced consolidation range of the lower lobe . During the telephone follow-up on December 16, we learned that the patient had successfully removed the closed thoracic drainage tube and was receiving further antineoplastic therapy.", + "fulltext_subclaims": [ + "On October 8, 2020, a 52-year-old Chinese female was admitted to a local state hospital with cough and expectoration.", + "A chest CT scan revealed an oblique fissure effusion in the right lung.", + "The patient was diagnosed as a pulmonary infection and treated empirically with levofloxacin at the local state hospital.", + "After 1 week of treatment with this regimen, the patient developed shortness of breath.", + "The supervising physician adjusted the treatment regimen to levofloxacin combined with latamoxef sodium.", + "After another 1 week of anti-infective treatment, the patient felt that her symptoms were relieved and asked to be discharged from the hospital.", + "The patient stopped taking antibiotics on her own.", + "After discharge, the patient’s shortness of breath gradually worsened.", + "On October 31, the patient went to the local state hospital again.", + "A repeat CT scan showed a large thick-walled cavity in the right lung.", + "Outpatient doctors suggested that the patient continue hospitalization.", + "On November 1st, the patient suffered from sudden pain in the right chest and difficulty breathing during hospitalization.", + "She was transferred to our hospital in the emergency department.", + "The patient used to have type 2 diabetes.", + "She had no history of joint pain.", + "She had no history of heart valvular disease.", + "She had no history of lung surgery.", + "She had no family history of the tumor.", + "CT re-examination revealed right hydropneumothorax and extensive compression atelectasis.", + "The patient was diagnosed with pyothorax.", + "Laboratory inspection showed WWBC 6.5 × 109/L.", + "Laboratory inspection showed PLT 298 × 109/L.", + "Laboratory inspection showed IL-6 955.2 pg/mL.", + "Laboratory inspection showed PCT 0.99 ng/mL.", + "Laboratory inspection showed CRP > 90 mg/L.", + "Laboratory inspection showed ALB 33.02 g/L.", + "Empirical treatment of moxifloxacin was given in the emergency.", + "On November 3, she was admitted to the intensive care unit.", + "Ultrasonic examination showed a localized anechoic area of 13.0 cm × 10.1 cm × 6.2 cm in the right thoracic cavity.", + "The patient was given moxifloxacin plus thoracic puncture and drainage.", + "The drainage was porridge-like, with a fishy smell.", + "The pus was sent for biochemical examination.", + "Dyspnea was improved after drainage of 1300 ml pleural effusion for 2 days.", + "On November 6, she was transferred to the general ward.", + "She continued to be treated with broad-spectrum moxifloxacin.", + "Fibrinolytic drugs were injected into the pleural cavity for 72 h.", + "During the treatment, the symptoms of shortness of breath worsened again.", + "Ultrasound re-examination showed a localized anechoic area of 12.5 cm × 6.8 cm × 6.7 cm in the right thoracic cavity.", + "The drainage device was replaced by closed thoracic drainage.", + "Intermittent drainage of 1000 ml pleural effusion was performed.", + "The drainage fluid was sent to 2 groups of blood culture on different days.", + "Each group included an aerobic bottle and an anaerobic bottle.", + "The culture results showed 3 strains of G. adiacens.", + "The culture results showed 1 strain of Eikenella corrodens.", + "The culture results showed 1 strain of Staphylococcus aureus.", + "G. adiacens were identified as the main pathogen due to its high detection rate.", + "The drug sensitivity test showed that G. adiacens was sensitive to penicillin.", + "The drug sensitivity test showed that G. adiacens was sensitive to erythromycin.", + "The drug sensitivity test showed that G. adiacens was sensitive to vancomycin.", + "The drug sensitivity test showed that G. adiacens was sensitive to cefotaxime.", + "The drug sensitivity test showed that G. adiacens was sensitive to levofloxacin.", + "The drug sensitivity test showed that G. adiacens was sensitive to linezolid.", + "According to the results of drug sensitivity, moxifloxacin treatment was continued.", + "Ornidazole was added to cover anaerobic bacteria.", + "Echocardiography examination showed local calcification of the aortic valve.", + "Echocardiography showed no valvular insufficiency.", + "Echocardiography showed no vegetation.", + "Echocardiography ruled out endocardial infection.", + "Bronchoscopy examination showed external compressive stenosis of the right middle bronchus.", + "Minced meat-like tissue of the lower lobe of the right lung was found in the bronchoscopy.", + "Pathological examination revealed adenocarcinoma.", + "On November 18, CT re-examination showed right pleural thickening.", + "On November 18, CT re-examination showed pleural effusion.", + "On November 18, CT re-examination showed multiple cord shadows in the middle and lower lobe bottom consolidation.", + "After multidisciplinary consultation, surgical intervention was suggested after the control of pulmonary infection.", + "On November 19, the patient went home with a drainage device.", + "The patient was given oral moxifloxacin as discharge drugs.", + "The patient was given oral ornidazole as discharge drugs.", + "Nutritional support lasted throughout the medication period.", + "On December 7, WBCC and CRP were in the normal range.", + "On December 7, CT showed right pleural thickening.", + "On December 7, CT showed obvious absorption of multiple cords in the middle and lower lobe of the right lung.", + "On December 7, CT showed slightly reduced consolidation range of the lower lobe.", + "During the telephone follow-up on December 16, the patient had successfully removed the closed thoracic drainage tube.", + "The patient was receiving further antineoplastic therapy." + ], + "summary": "A 52-year-old Chinese woman was admitted to the hospital, She complained of coughing and expectoration for 1 month, shortness of breath for half a month, and dyspnea for 1 day. After a series of examinations, she was diagnosed with lung abscess, pleural effusion, and bronchogenic carcinoma. Draining pus culture demonstrated Granulicatella adiacens. After more than 5 weeks of antibiotic therapies in total, she gradually recovered to fight against lung cancer.", + "summary_subclaims": [ + "The patient is a 52-year-old Chinese woman.", + "She complained of coughing and expectoration for 1 month.", + "She complained of shortness of breath for half a month.", + "She complained of dyspnea for 1 day.", + "She was diagnosed with lung abscess.", + "She was diagnosed with pleural effusion.", + "She was diagnosed with bronchogenic carcinoma.", + "Draining pus culture demonstrated Granulicatella adiacens.", + "She received more than 5 weeks of antibiotic therapies in total.", + "She gradually recovered to fight against lung cancer." + ] + }, + { + "id": "multiclinsum_test_2842_en.txt", + "fulltext": "A 20-year-old male with no known past medical history or allergies presented to the emergency department (ED) complaining of acute, sudden onset, left forearm pain and rash. The patient was working at an eyeglasses and contacts store and stated that the pain started when he knelt to lift something up from ground level. In doing so, he placed his left elbow on his left thigh. He immediately felt a stinging sensation in his left elbow with severe 10/10 pain radiating down the extremity to the left forearm and hand. Shortly afterward he noticed the affected area had become erythematous, thus he presented to the ED for an emergent medical evaluation. Pertinent negatives included absence of fever, chills, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, urinary complaints, back pain, and headache.\nThe patient arrived hypertensive with initial blood pressure measuring 130/91 millimeters of mercury. Triage vital signs were otherwise normal. On physical examination, the patient appeared anxious. The primary survey of airway, breathing, and circulation was unremarkable. Focused examination of the affected region demonstrated an approximately 1 × 2-cm area of erythema and edema over the proximal posterior forearm with an associated grid-like pattern of raised urticaria. The rash was localized and did not exhibit desquamation .\nThe left upper extremity was otherwise neurovascularly intact with a palpable radial pulse and capillary refill less than three seconds. Assessment of motor function and active and passive range of motion at the elbow was normal. Laboratory assessment and imaging were determined to be of no utility and were not ordered. Upon further inquiry, the patient mentioned that his arm may have contacted a caterpillar, which was found on the ground at the site where his pain first began. A photo of the caterpillar was eventually obtained and provided on the patient’s smartphone .\nThe emergency physician called the Poison Control Center (PCC) hotline, which confirmed that the symptoms were likely the result of an asp caterpillar envenomation. Of note, the expert at the PCC mentioned that the presentation was particularly unusual given that it occurred in a commercial building devoid of trees and foliage. Other diagnoses considered were allergic reaction, insect bite/sting, contact dermatitis, cellulitis, and traumatic injury.\nTherapeutic management focused on aggressive symptom management. Due to concern for a developing hypersensitivity reaction, dexamethasone 8 milligrams (mg) intravenous (IV), acetaminophen-codeine 300-30 mg per os (PO), famotidine 20 mg IV, ketorolac 30 mg IV, and diphenhydramine 25 mg IV were administered. Upon further inspection of the affected area, several spines were visualized penetrating the patient’s skin. Silk tape was applied to the affected area and carefully removed, thus stripping away the offending spines. The patient’s pain rapidly improved. The patient received an additional 25 micrograms of fentanyl IV after reassessment an hour later. He underwent a period of observation in the ED and was discharged with prescriptions for methylprednisolone 4 mg PO and oxycodone-acetaminophen 5–325 mg PO. Attempts to contact him after discharge to arrange follow-up and a wound check were unsuccessful. There were no subsequent patient encounters documented in the electronic health record.", + "fulltext_subclaims": [ + "The patient is a 20-year-old male.", + "The patient has no known past medical history.", + "The patient has no known allergies.", + "The patient presented to the emergency department with acute, sudden onset, left forearm pain and rash.", + "The patient was working at an eyeglasses and contacts store.", + "The pain started when the patient knelt to lift something from the ground.", + "The patient placed his left elbow on his left thigh.", + "The patient immediately felt a stinging sensation in his left elbow.", + "The patient experienced severe 10/10 pain radiating down the left extremity to the forearm and hand.", + "The patient noticed erythema shortly after the pain started.", + "The patient presented to the ED for an emergent medical evaluation.", + "The patient had no fever.", + "The patient had no chills.", + "The patient had no cough.", + "The patient had no shortness of breath.", + "The patient had no chest pain.", + "The patient had no nausea.", + "The patient had no vomiting.", + "The patient had no diarrhea.", + "The patient had no urinary complaints.", + "The patient had no back pain.", + "The patient had no headache.", + "The patient arrived hypertensive with an initial blood pressure of 130/91 mmHg.", + "Triage vital signs were otherwise normal.", + "The patient appeared anxious.", + "The primary survey of airway, breathing, and circulation was unremarkable.", + "Focused examination showed an approximately 1 × 2-cm area of erythema and edema over the proximal posterior forearm.", + "The rash had a grid-like pattern of raised urticaria.", + "The rash was localized.", + "The rash did not exhibit desquamation.", + "The left upper extremity was neurovascularly intact.", + "The radial pulse was palpable.", + "Capillary refill was less than three seconds.", + "Assessment of motor function and active and passive range of motion at the elbow was normal.", + "Laboratory assessment was not ordered.", + "Imaging was not ordered.", + "The patient mentioned his arm may have contacted a caterpillar.", + "The caterpillar was found on the ground at the site where the pain first began.", + "A photo of the caterpillar was obtained on the patient’s smartphone.", + "The emergency physician called the Poison Control Center hotline.", + "The PCC confirmed the symptoms were likely due to an asp caterpillar envenomation.", + "The PCC noted the presentation was unusual given it occurred in a commercial building without trees and foliage.", + "Other diagnoses considered included allergic reaction, insect bite/sting, contact dermatitis, cellulitis, and traumatic injury.", + "Dexamethasone 8 mg IV was administered.", + "Acetaminophen-codeine 300-30 mg PO was administered.", + "Famotidine 20 mg IV was administered.", + "Ketorolac 30 mg IV was administered.", + "Diphenhydramine 25 mg IV was administered.", + "Several spines were visualized penetrating the patient’s skin.", + "Silk tape was applied to the affected area and carefully removed.", + "The patient’s pain rapidly improved.", + "The patient received an additional 25 micrograms of fentanyl IV after reassessment an hour later.", + "The patient was discharged with prescriptions for methylprednisolone 4 mg PO.", + "The patient was discharged with prescriptions for oxycodone-acetaminophen 5–325 mg PO.", + "Attempts to contact the patient after discharge were unsuccessful.", + "There were no subsequent patient encounters documented in the electronic health record." + ], + "summary": "We present the case of a patient presenting to the emergency department (ED) with acute-onset severe left forearm pain with associated pruritic rash incurred while working in a retail store. Initial therapeutic management included administration of analgesics, antihistamines, and steroids. After obtaining a comprehensive history and consulting with the Poison Control Center, we suspected an asp caterpillar envenomation. Following extraction of the caterpillar spines with silk tape, the patient's symptoms improved. After a period of observation in the ED, the patient was discharged home without any known sequelae.", + "summary_subclaims": [ + "The patient presented to the emergency department with acute-onset severe left forearm pain.", + "The patient had an associated pruritic rash.", + "The injury occurred while working in a retail store.", + "Initial therapeutic management included administration of analgesics.", + "Initial therapeutic management included administration of antihistamines.", + "Initial therapeutic management included administration of steroids.", + "We suspected an asp caterpillar envenomation.", + "Extraction of the caterpillar spines was performed with silk tape.", + "The patient's symptoms improved after spine extraction.", + "The patient was discharged home after a period of observation in the ED.", + "The patient had no known sequelae after discharge." + ] + }, + { + "id": "multiclinsum_test_283_en.txt", + "fulltext": "During August 2017, a 65year-old female was admitted to our department with histological finding of EPC of the right leg. One month before, she underwent surgical excision of a cutaneous lesion of the right leg. This lesion appeared brownish, exophytic, with ulcerated surface, more suggestive for a squamous cell carcinoma than an ulcerated nodular basal cell carcinoma. The histological examination revealed a poroid neoplasm extending into the reticular dermis with a thickness of 5 mm, 10 mitoses per 10 high-power field, absence of lymphovascular invasion and free margins with a clearing distance of 2 mm. shows the hematoxylin-eosin stain picture of the lesion.\nShe had a past medical history of hysterectomy and bilateral salpingo-oophorectomy for uterine fibromatosis, kidney transplantation for severe chronic renal failure, high blood pressure, aneurysmal dilatation of the right common carotid artery, hypercholesterolemia, hyperparathyroidism and previous inferior myocardial infarction. Laboratory tests, including blood count, biochemical investigations and serum viral markers were normal. After multidisciplinary discussion and based on the sub-optimal clearing margin we performed a re-excision of the previous wound to ensure wider safety margins of at least 20 mm. It was also decided to perform a SLNB; the pre-operative lymph node scintigraphy showed the presence of two sentinel lymph nodes in the right inguinal site. The patient underwent enlargement of the surgical excision until 20 mm of free margin from the previous excision and SLNB of the two lymph nodes identified preoperatively. Recovery from surgery was uneventful and the patient was discharged from hospital on the first post-operative day. Histopathological examination found no signs of residual or satellite neoplasia in the surgical sample and the two retrieved sentinel lymph nodes were negative for metastatic disease. Patient is disease free 7 months after the operation and continues follow- up.", + "fulltext_subclaims": [ + "The patient was a 65-year-old female.", + "She was admitted in August 2017.", + "The histological finding was EPC of the right leg.", + "One month before admission, she underwent surgical excision of a cutaneous lesion of the right leg.", + "The lesion appeared brownish, exophytic, with ulcerated surface.", + "The lesion was more suggestive for a squamous cell carcinoma than an ulcerated nodular basal cell carcinoma.", + "The histological examination revealed a poroid neoplasm extending into the reticular dermis.", + "The neoplasm had a thickness of 5 mm.", + "There were 10 mitoses per 10 high-power field.", + "There was absence of lymphovascular invasion.", + "The clearing distance was 2 mm.", + "The patient had a past medical history of hysterectomy and bilateral salpingo-oophorectomy for uterine fibromatosis.", + "She had kidney transplantation for severe chronic renal failure.", + "She had high blood pressure.", + "She had aneurysmal dilatation of the right common carotid artery.", + "She had hypercholesterolemia.", + "She had hyperparathyroidism.", + "She had a previous inferior myocardial infarction.", + "Laboratory tests, including blood count, biochemical investigations and serum viral markers, were normal.", + "A re-excision of the previous wound was performed.", + "The re-excision was based on sub-optimal clearing margin.", + "The goal was to ensure wider safety margins of at least 20 mm.", + "A SLNB was decided.", + "The pre-operative lymph node scintigraphy showed two sentinel lymph nodes in the right inguinal site.", + "The patient underwent enlargement of the surgical excision until 20 mm of free margin from the previous excision.", + "The patient underwent SLNB of the two lymph nodes identified preoperatively.", + "Recovery from surgery was uneventful.", + "The patient was discharged from hospital on the first post-operative day.", + "Histopathological examination found no signs of residual or satellite neoplasia in the surgical sample.", + "The two retrieved sentinel lymph nodes were negative for metastatic disease.", + "The patient is disease free 7 months after the operation.", + "The patient continues follow-up." + ], + "summary": "The Authors report two cases of EPC of the lower limbs occurred in two women. Patients were treated by wide surgical excision of the lesion and SNLB. 6 months follow-up was disease free for both patients.", + "summary_subclaims": [ + "The Authors report two cases of EPC of the lower limbs occurred in two women.", + "Patients were treated by wide surgical excision of the lesion and SNLB.", + "6 months follow-up was disease free for both patients." + ] + }, + { + "id": "multiclinsum_test_2144_en.txt", + "fulltext": "A 41-year-old, previously healthy Sri Lankan female presented with sudden onset severe headache for one day. The headache started in the occipital region and spread towards the vertex. It worsened with standing and was accompanied with nausea and vomiting. The patient described it as her ‘worst-ever’ headache. She denied a past history of migraine. Remarkably, the headache resolved with lying supine and recurred on sitting up or standing. It would commence as a sensation of ‘heaviness’ of her head that would gradually progress to a severe, disabling headache. The maximum duration that she could tolerate an upright posture was approximately one hour. She did not have any other co-morbidities and denied use of any medicinal or recreational drugs. There was no history of surgery or trauma involving the head, neck or spine.\nOn examination, she was comfortable in the supine position and detested sitting up or standing. The cardiovascular, respiratory, abdominal and nervous system examinations were normal.\nHaematological and biochemical blood investigations including full blood count, electrolytes, random blood glucose, liver and renal function tests, erythrocyte sedimentation rate and C-reactive protein were normal. Electrocardiogram was normal. Computerised tomography (CT) scan of the head did not reveal any abnormality. However, gadolinium-enhanced magnetic resonance imaging (MRI) showed generalized meningeal enhancement . The MR angiogram was normal.\nLumbar puncture done in the lateral decubitus position revealed a CSF opening pressure of less than 30 mm of H2O. The biochemical, cytological and microbiological analysis of CSF was normal and there was no xanthochromia. MR myelography failed to identify the site of CSF leak.\nThe patient was managed with bed-rest and hydration with infusions of normal saline. She was prescribed analgesics and encouraged to drink excess amounts of coffee ad libitum. Over the ensuing 3 months, her headaches became less intense and she could progressively tolerate longer durations in the upright posture. At three months’ review she was able to maintain her upright posture for up to 6 hours without headache. Since she showed small but definite improvement each day, the plan for epidural blood patching (EBP) was perpetually deferred. However, in retrospect, given the protracted time to recovery it would have been appropriate to have instituted EBP earlier.", + "fulltext_subclaims": [ + "The patient is a 41-year-old, previously healthy Sri Lankan female.", + "She presented with sudden onset severe headache for one day.", + "The headache started in the occipital region and spread towards the vertex.", + "The headache worsened with standing.", + "The headache was accompanied with nausea and vomiting.", + "The patient described it as her ‘worst-ever’ headache.", + "She denied a past history of migraine.", + "The headache resolved with lying supine.", + "The headache recurred on sitting up or standing.", + "The maximum duration that she could tolerate an upright posture was approximately one hour.", + "She did not have any other co-morbidities.", + "There was no history of surgery or trauma involving the head, neck or spine.", + "On examination, she was comfortable in the supine position.", + "The cardiovascular, respiratory, abdominal and nervous system examinations were normal.", + "Haematological and biochemical blood investigations were normal.", + "Computerised tomography (CT) scan of the head did not reveal any abnormality.", + "Gadolinium-enhanced magnetic resonance imaging (MRI) showed generalized meningeal enhancement.", + "Lumbar puncture done in the lateral decubitus position revealed a CSF opening pressure of less than 30 mm of H2O.", + "The biochemical, cytological and microbiological analysis of CSF was normal.", + "MR myelography failed to identify the site of CSF leak.", + "The patient was managed with bed-rest and hydration with infusions of normal saline.", + "She was prescribed analgesics.", + "She was encouraged to drink excess amounts of coffee ad libitum.", + "Over the ensuing 3 months, her headaches became less intense.", + "She could progressively tolerate longer durations in the upright posture.", + "At three months’ review she was able to maintain her upright posture for up to 6 hours without headache.", + "Since she showed small but definite improvement each day, the plan for epidural blood patching (EBP) was perpetually deferred.", + "In retrospect, given the protracted time to recovery it would have been appropriate to have instituted EBP earlier." + ], + "summary": "A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture. Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement and normal magnetic resonance angiography while lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water. Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak. The patient was managed conservatively with bed-rest, intravenous hydration, analgesics and an increased intake of oral coffee which led to a gradual relief of headaches in the upright posture.", + "summary_subclaims": [ + "The patient is a 41-year-old Sri Lankan female.", + "She presented with thunderclap headache.", + "The headache was associated with nausea and vomiting.", + "The headache was characterized by positional variation.", + "The headache was aggravated in the upright posture.", + "The headache was relieved in the supine posture.", + "Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement.", + "Magnetic resonance angiography was normal.", + "Lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water.", + "Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak.", + "The patient was managed conservatively with bed-rest.", + "The patient received intravenous hydration.", + "The patient was given analgesics.", + "The patient was advised to increase intake of oral coffee.", + "The patient experienced a gradual relief of headaches in the upright posture." + ] + }, + { + "id": "multiclinsum_test_2400_en.txt", + "fulltext": "We report here a case of 37-year old woman with schizophrenia, hospitalized for an exacerbation of psychotic symptoms. She had no personal/family history of cardiac diseases or sudden deaths. Besides benzodiazepines, she was treated at the admission with aripiprazol (20 mg/day), haloperidol (3 mg/day) and escitalopram (20 mg/day). The routine laboratory and clinical check-up (including ECG and blood electrolytes) revealed no abnormalities. The patient developed the aLQTS in response to small doses of risperidone (1–2 mg/day), confirmed at three independent drug challenges. Noteworthy, the patient responded with significant QT prolongation to risperidone (QTc increase from 458 to 508 ms), also when all other drugs, which might potentially affect QT length, were discontinued (Figure ). The reason of this extreme sensitivity to risperidone was unclear but the contribution of a cytochrome polymorphism or other elimination failures is unlikely since risperidone prolonged QT at very low blood concentrations (19.1 nM). Moreover, the concentration of paliperidone, an active metabolite of risperidone with QT-prolonging potential , was very low too, and the cumulative blood concentration of risperidone and paliperidone was subtherapeutic. Interestingly, the patient did not respond with QT prolongation following the administration of other antipsychotics (e.g. aripiprazol, clothiapine, haloperidol; data not depicted). In particular, the administration of clozapine, known to be associated with higher QT-prolongation risk than risperidone , had no effect on QT-length (Figure ).\nWe hypothesized that our patient carries a mutation or polymorphism in the KCNH2, which could determine conformational alterations of the channel and thus differentially affect its capacity to bind risperidone and clozapine. Therefore, we have sequenced all the coding exons and exon-intron boundaries of the KCNH2 (isoforms 1a and 1b), but no mutation or polymorphism was found (data not depicted). We have also excluded any mutation in the SCN5A gene, as well as in the KCNE2 (data not depicted), the gene encoding the β–subunit of the Ikr channel, as well as G38S and D85N polymorphism in the KCNE1, reported to cause the LQTS [,]. Since a subtle mutation in the KCNQ1 could affect the repolarisation reserve, indirectly leading to the aLQTS [,], we have sequenced also this gene but found no mutation (data not depicted). Additionally, we have excluded any exonic deletion and duplication of the KCNH2 by Multiplex Ligation-dependent Probe Amplification (data not depicted; P114-A2-LQT probemix, MRC-Holland).", + "fulltext_subclaims": [ + "The patient was a 37-year-old woman with schizophrenia.", + "She was hospitalized for an exacerbation of psychotic symptoms.", + "She had no personal/family history of cardiac diseases or sudden deaths.", + "She was treated at admission with aripiprazol (20 mg/day), haloperidol (3 mg/day), and escitalopram (20 mg/day).", + "The routine laboratory and clinical check-up, including ECG and blood electrolytes, revealed no abnormalities.", + "The patient developed acquired long QT syndrome (aLQTS) in response to small doses of risperidone (1–2 mg/day).", + "The aLQTS was confirmed at three independent drug challenges.", + "The patient responded with significant QT prolongation to risperidone (QTc increase from 458 to 508 ms).", + "The QT prolongation occurred even when all other drugs potentially affecting QT length were discontinued.", + "The blood concentration of risperidone was 19.1 nM.", + "The concentration of paliperidone, an active metabolite of risperidone, was very low.", + "The cumulative blood concentration of risperidone and paliperidone was subtherapeutic.", + "The patient did not respond with QT prolongation following the administration of other antipsychotics.", + "The administration of clozapine had no effect on QT-length.", + "We hypothesized that the patient carries a mutation or polymorphism in the KCNH2.", + "We sequenced all the coding exons and exon-intron boundaries of the KCNH2 (isoforms 1a and 1b), but no mutation or polymorphism was found.", + "We excluded any mutation in the SCN5A gene.", + "We excluded any mutation in the KCNE2 gene.", + "We excluded the G38S and D85N polymorphism in the KCNE1.", + "We sequenced the KCNQ1 gene but found no mutation.", + "We excluded any exonic deletion and duplication of the KCNH2 by Multiplex Ligation-dependent Probe Amplification." + ], + "summary": "We report here a case of aLQTS in response to small doses of risperidone that was confirmed at three independent drug challenges in the absence of other QT-prolonging drugs. On the other hand, the patient did not respond with QT prolongation to some other antipsychotics. In particular, the administration of clozapine, known to be associated with higher QT-prolongation risk than risperidone, had no effect on QT-length. A detailed genetic analysis revealed no mutations or polymorphisms in KCNH2, KCNE1, KCNE2, SCN5A and KCNQ1 genes.", + "summary_subclaims": [ + "The patient had aLQTS in response to small doses of risperidone.", + "The aLQTS was confirmed at three independent drug challenges.", + "Other QT-prolonging drugs were not present during the challenges.", + "The patient did not respond with QT prolongation to some other antipsychotics.", + "Clozapine had no effect on QT-length.", + "Clozapine is known to be associated with higher QT-prolongation risk than risperidone.", + "A detailed genetic analysis revealed no mutations or polymorphisms in KCNH2, KCNE1, KCNE2, SCN5A and KCNQ1 genes." + ] + }, + { + "id": "multiclinsum_test_95_en.txt", + "fulltext": "A 34-year-old woman with an unremarkable past medical and family history presented at the emergency room with symptoms of nausea, abdominal discomfort, and pallor for 7 days. High blood pressure levels were recorded all days. She had previously received nonsteroidal anti-inflammatory drug treatment for toothache for 3 days. There was no recent history of diarrhea, dysentery-like illness, pregnancy, miscarriage, or use of contraceptives.\nPhysical examination of the patient revealed pallor of the skin and mucous membranes. Her blood pressure was 155/100 mm Hg. Otherwise, physical examination was unremarkable.\nLaboratory tests were indicative of microangiopathic hemolytic anemia with hemoglobin levels of 9.4 g/dL (normal range, 12.2–16.1 g/dL). Peripheral blood smear revealed anisopoikilocytosis (red blood cells of varying shapes and sizes), including the presence of fragmented red blood cells (schistocytes and helmet cells). Coomb's test was negative, and haptoglobin was absent. The platelet count was 27,000/mm3. Renal damage was present, with serum creatinine levels of 5.8 mg/dL (normal range, 0.43−0.9 mg/dL), urea levels of 173 mg/dL, phosphorus levels of 6.4 mg/dL, and lactate dehydrogenase levels of 1,394 UI/L. There were no further pathological biochemical parameters. Urinalysis revealed 3+ albumin, and microscopy of the urine sediment yielded 5–7 red cells per X power field. Prothrombin time was 12 s, and activated partial thromboplastin time was 26.5 s. Antinuclear antibodies, antiphospholipid antibodies, rheumatoid factor, anti-neutrophil cytoplasmic antibody, and anti-native DNA antibodies were not detected. Blood and urine cultures were sterile. The patient's serum tested negative for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. A hyperechogenic cortex was displayed on the renal ultrasound scan. The exploration was otherwise normal. Renal biopsy was not performed.\nAfter ruling out secondary causes of thrombotic microangiopathy, a definitive diagnosis of aHUS was made. Plasma exchange was initiated with the patient receiving exchanges twice daily, for a total of 31 sessions. However, her renal function did not improve, and hemodialysis therapy was subsequently initiated.\nA further diagnostic workup was performed. ADAMTS13 activity in the plasma was 86.5% (normal range, 40–124%) and thus, it was found to be normal. The plasma concentrations of complement components were as follows: C3, 73.6 mg/dL (normal range, 77–210 mg/dL), C4, 28.4 g/L (normal range, 14–47 g/L), and CFH, 21.37 mg/dL (normal range, 12–56 mg/dL). CFI activity was 85% (normal range, 71–115%), MCP was 117% (normal range, 91–109%), and anti-CFH antibodies were absent. Mutation screening of CFH, CFI, CD46, C3, and CFB was conducted. This analysis revealed a heterozygous single-nucleotide mutation in the exon 13 of the CFH gene (c.1707>A; Cys569stop) that was predicted to truncate the protein product by introducing a stop codon (Cys569stop). This mutation was not defined in the Exome Sequencing Project. No mutations were found either for CFI or MCP genes. Moreover, the patient carries the CFH and MCP risk haplotypes for aHUS in heterozygous pattern.\nThe patient was switched to automated peritoneal dialysis (APD) after almost 2 months of hemodialysis. Her APD schedule consisted of 5 overnight exchanges of 2 L and 1 icodextrin (extraneal) wet day. At this moment, the patient's residual renal function (RRF) was 3–4 mL/min, and her urine output was 700 mL per day (urea clearance of 1,400 mg/dL and creatinine clearance of 108 mg/dL). Blood pressure remained poorly controlled (>163/105 mm Hg) despite administration of maximal doses of 6 different antihypertensive drugs. Platelet count was 103,000/mm3, and hemoglobin level was 12.2 g/dL.\nSixty-two months following diagnosis and treatment with dialysis, the patient remained on APD with sustained high blood pressure, anemia and thrombocytopenia. At this point, she was re-evaluated, as her clinical symptoms and hematological and biochemical profile remained poorly controlled. Treatment with complement-blocking therapy with eculizumab was initiated. At the time of initiation of eculizumab, the patient was asymptomatic and in good clinical status. Blood pressure values remained 160/105 mm Hg despite the use of full doses of 6 hypotensive drugs (verapamil, trandolapril, atenolol, doxazosin, aliskiren, and furosemide). Platelet count was 103,000/mm3. Diuresis was 700 mL with proteinuria of 0.3 g/L and creatinine of 7.53 mg/dL. RRF was 3.9 mL/min (urea clearance of 2.2 mL/min and creatinine clearance of 5.6 mL/min). The patient was on continuous cycling peritoneal dialysis with 10 L overnight exchanges and 2 L of icodextrin during the day. In order to prevent meningococcal infection, the patient received prophylactic antibiotic treatment with ciprofloxacin and vaccination against Neisseria meningitides before receiving the first dose of eculizumab on August 5, 2013. Follow-up was performed every 3 months . The patient's clinical condition improved within 6 months of starting eculizumab therapy: RRF increased to 11 mL/min and urine output increased to 2,000 mL per day. Levels of hemoglobin, platelets, and lactate dehydrogenase returned to normal ranges. The patient's blood pressure was better controlled with 4 drugs (furosemide, verapamil, trandolapril, and metoprolol), with levels below 120/70 mm Hg . Improvement was sustained through successive follow-up visits. Fifteen months after the initiation of eculizumab, kidney creatinine clearance rate was 30 mL/min, RRF was 20 mL/min, and urine output was 2,300 mL per day. At 16 months of follow-up, APD dose was reduced to 3 overnight exchanges of 2 L, 5 days per week, and extraneal exchange and wet day were no longer required. Currently, dialysis has been successfully discontinued.\nTreatment with eculizumab was well tolerated by the patient throughout the follow-up period. At present, and in anticipation of her progress in the next months, we are evaluating the options of either keeping the patient under supervision for advanced renal disease or including her in the renal transplant waiting list.", + "fulltext_subclaims": [ + "The patient is a 34-year-old woman.", + "She had an unremarkable past medical and family history.", + "She presented with symptoms of nausea, abdominal discomfort, and pallor for 7 days.", + "High blood pressure levels were recorded all days.", + "She had previously received nonsteroidal anti-inflammatory drug treatment for toothache for 3 days.", + "There was no recent history of diarrhea.", + "There was no recent history of dysentery-like illness.", + "There was no recent history of pregnancy.", + "There was no recent history of miscarriage.", + "There was no recent history of use of contraceptives.", + "Physical examination revealed pallor of the skin and mucous membranes.", + "Her blood pressure was 155/100 mm Hg.", + "Laboratory tests were indicative of microangiopathic hemolytic anemia.", + "Hemoglobin levels were 9.4 g/dL.", + "Peripheral blood smear revealed anisopoikilocytosis.", + "Coomb's test was negative.", + "Haptoglobin was absent.", + "The platelet count was 27,000/mm3.", + "Serum creatinine levels were 5.8 mg/dL.", + "Urinalysis revealed 3+ albumin.", + "A definitive diagnosis of aHUS was made.", + "Plasma exchange was initiated with the patient receiving exchanges twice daily, for a total of 31 sessions.", + "Her renal function did not improve.", + "Hemodialysis therapy was subsequently initiated.", + "ADAMTS13 activity in the plasma was 86.5%.", + "The plasma concentration of C3 was 73.6 mg/dL.", + "The plasma concentration of C4 was 28.4 g/L.", + "The plasma concentration of CFH was 21.37 mg/dL.", + "CFI activity was 85%.", + "MCP was 117%.", + "Anti-CFH antibodies were absent.", + "Mutation screening of CFH, CFI, CD46, C3, and CFB was conducted.", + "A heterozygous single-nucleotide mutation in the exon 13 of the CFH gene (c.1707>A; Cys569stop) was found.", + "The patient carries the CFH and MCP risk haplotypes for aHUS in heterozygous pattern.", + "The patient was switched to automated peritoneal dialysis after almost 2 months of hemodialysis.", + "Her APD schedule consisted of 5 overnight exchanges of 2 L and 1 icodextrin (extraneal) wet day.", + "Her residual renal function was 3–4 mL/min.", + "Her urine output was 700 mL per day.", + "Blood pressure remained poorly controlled (>163/105 mm Hg) despite administration of maximal doses of 6 different antihypertensive drugs.", + "Platelet count was 103,000/mm3.", + "Hemoglobin level was 12.2 g/dL.", + "Sixty-two months following diagnosis and treatment with dialysis, the patient remained on APD.", + "She was re-evaluated as her clinical symptoms and hematological and biochemical profile remained poorly controlled.", + "Treatment with complement-blocking therapy with eculizumab was initiated.", + "At the time of initiation of eculizumab, the patient was asymptomatic and in good clinical status.", + "Blood pressure values remained 160/105 mm Hg despite the use of full doses of 6 hypotensive drugs.", + "Platelet count was 103,000/mm3.", + "Diuresis was 700 mL with proteinuria of 0.3 g/L.", + "Creatinine was 7.53 mg/dL.", + "The patient was on continuous cycling peritoneal dialysis with 10 L overnight exchanges and 2 L of icodextrin during the day.", + "The patient received prophylactic antibiotic treatment with ciprofloxacin.", + "The patient received vaccination against Neisseria meningitides before receiving the first dose of eculizumab.", + "The first dose of eculizumab was on August 5, 2013.", + "Follow-up was performed every 3 months.", + "The patient's clinical condition improved within 6 months of starting eculizumab therapy.", + "RRF increased to 11 mL/min.", + "Urine output increased to 2,000 mL per day.", + "Levels of hemoglobin, platelets, and lactate dehydrogenase returned to normal ranges.", + "The patient's blood pressure was better controlled with 4 drugs, with levels below 120/70 mm Hg.", + "Improvement was sustained through successive follow-up visits.", + "Fifteen months after the initiation of eculizumab, kidney creatinine clearance rate was 30 mL/min.", + "RRF was 20 mL/min.", + "Urine output was 2,300 mL per day.", + "At 16 months of follow-up, APD dose was reduced to 3 overnight exchanges of 2 L, 5 days per week.", + "Extraneal exchange and wet day were no longer required.", + "Dialysis has been successfully discontinued.", + "Treatment with eculizumab was well tolerated by the patient throughout the follow-up period.", + "We are evaluating the options of either keeping the patient under supervision for advanced renal disease or including her in the renal transplant waiting list." + ], + "summary": "A 34-year-old woman showed symptoms and laboratory findings consistent with atypical hemolytic-uremic syndrome. Genetic analysis revealed an unusual mutation of the complement regulatory gene not seen previously. Due to unavailability of eculizumab at the time of presentation, conventional treatment was started with poor response. Late initiation of eculizumab resulted in discontinuation of peritoneal dialysis and yielded a good and sustained clinical response.", + "summary_subclaims": [ + "The patient was a 34-year-old woman.", + "The patient showed symptoms and laboratory findings consistent with atypical hemolytic-uremic syndrome.", + "Genetic analysis revealed an unusual mutation of the complement regulatory gene not seen previously.", + "Eculizumab was unavailable at the time of presentation.", + "Conventional treatment was started.", + "Conventional treatment resulted in poor response.", + "Eculizumab was initiated late.", + "Late initiation of eculizumab resulted in discontinuation of peritoneal dialysis.", + "Late initiation of eculizumab yielded a good and sustained clinical response." + ] + }, + { + "id": "multiclinsum_test_1109_en.txt", + "fulltext": "A 3-year-old girl was brought by her parents to the neurosurgery department with complaints of difficulty walking for 4 months. The patient had a backward bending posture while walking. She swayed to one side and dragged her right lower limb. She also had difficulty wearing her slippers. She was not able to bend forward or sit for a long duration of time. Ten months ago, she had a history of headaches that lasted for a week. The patient also had urinary incontinence for 4 months. The patient had one episode of seizures post which she developed lower limb weakness. There was no history of trauma to the spine and no history of coming in contact with a patient who had TB. The patient was vaccinated according to the World Health Organization schedule. The patient had a history of pneumonia at the age of 1 month, following which she was admitted to the intensive care unit for 1 week.\nOn examination, vitals were stable. Neurological examination showed that the tone of both lower limbs was increased. Plantar reflexes were extensor bilaterally. A magnetic resonance imaging (MRI) from an outside clinic showed a hyperintense intramedullary lesion, on T2W imaging, from T6 to T9 . On sagittal T1W imaging, with contrast, there was a fusiform dilation of the cord at the same levels with no enhancement. A similar finding was present on the axial cuts . The scan also showed hydrocephalus. However, on examination, there were no signs of raised intracranial pressure (ICP). The child underwent a T6 to T9 laminoplasty with intramedullary lesion decompression under neuromonitoring. Intraoperatively, the lesion was yellowish, fibrous, and densely adherent to underlying cord and nerve roots. Hence, only debulking of the lesion was performed. Postoperatively, mild deterioration of motor power in both lower limbs was noted. Histopathological examination of the lesion showed features suggestive of tuberculous granulomatous inflammation .\nThe diagnosis was then established. A pulmonology consultation for initiation of antitubercular treatment (ATT) was taken. The child was started on ATT and was subsequently discharged after being symptomatically better. The patient was reviewed 8 months after her initial visit while still on ATT, and she showed improvement in her gait abnormalities and is walking with support. The review scans showed complete resolution of the lower lesion but now showed evidence of chronic arachnoid adhesions at the T3 level. A CT brain performed at the same time showed evidence of hydrocephalus, most likely noncommunicating in nature . This may be due to tubercular meningitis or arachnoiditis. The patient was advised to continue her ATT and was discharged.", + "fulltext_subclaims": [ + "The patient is a 3-year-old girl.", + "The patient had difficulty walking for 4 months.", + "The patient had a backward bending posture while walking.", + "The patient swayed to one side and dragged her right lower limb.", + "The patient had difficulty wearing her slippers.", + "The patient was not able to bend forward or sit for a long duration of time.", + "Ten months ago, the patient had a history of headaches that lasted for a week.", + "The patient had urinary incontinence for 4 months.", + "The patient had one episode of seizures.", + "The patient developed lower limb weakness after the seizure.", + "There was no history of trauma to the spine.", + "There was no history of coming in contact with a patient who had TB.", + "The patient was vaccinated according to the World Health Organization schedule.", + "The patient had a history of pneumonia at the age of 1 month.", + "The patient was admitted to the intensive care unit for 1 week after the pneumonia.", + "Neurological examination showed increased tone of both lower limbs.", + "Plantar reflexes were extensor bilaterally.", + "An MRI showed a hyperintense intramedullary lesion on T2W imaging from T6 to T9.", + "On sagittal T1W imaging with contrast, there was a fusiform dilation of the cord at the same levels with no enhancement.", + "A similar finding was present on the axial cuts.", + "The scan also showed hydrocephalus.", + "There were no signs of raised intracranial pressure on examination.", + "The child underwent a T6 to T9 laminoplasty with intramedullary lesion decompression under neuromonitoring.", + "Intraoperatively, the lesion was yellowish, fibrous, and densely adherent to the underlying cord and nerve roots.", + "Only debulking of the lesion was performed.", + "Postoperatively, mild deterioration of motor power in both lower limbs was noted.", + "Histopathological examination showed features suggestive of tuberculous granulomatous inflammation.", + "A pulmonology consultation for initiation of antitubercular treatment was taken.", + "The child was started on antitubercular treatment.", + "The patient was discharged after being symptomatically better.", + "Eight months after the initial visit, the patient showed improvement in gait abnormalities and was walking with support.", + "Review scans showed complete resolution of the lower lesion.", + "Review scans showed evidence of chronic arachnoid adhesions at the T3 level.", + "A CT brain showed evidence of hydrocephalus, most likely noncommunicating in nature.", + "This may be due to tubercular meningitis or arachnoiditis.", + "The patient was advised to continue her antitubercular treatment." + ], + "summary": "A young vaccinated girl presented to the neurosurgery department with difficulty walking and urinary incontinence. A magnetic resonance imaging performed outside the hospital showed a hyperintense intramedullary lesion extending from T6 to T9. The patient underwent T6-T9 laminoplasty with intramedullary lesion decompression under neuromonitoring. The dense adherence of the lesion to the cord and nerve roots permitted only debulking. Histopathological examination confirmed the diagnosis of tuberculoma. The patient was started on antitubercular treatment and was then subsequently discharged. After 8 months, the patient was reviewed and showed improvement in her symptoms and complete resolution of the lesion on imaging. The patient has now developed hydrocephalus on the latest computed tomography imaging, which may be due to tubercular meningitis or arachnoiditis.", + "summary_subclaims": [ + "A young vaccinated girl presented to the neurosurgery department with difficulty walking and urinary incontinence.", + "A magnetic resonance imaging performed outside the hospital showed a hyperintense intramedullary lesion extending from T6 to T9.", + "The patient underwent T6-T9 laminoplasty with intramedullary lesion decompression under neuromonitoring.", + "The dense adherence of the lesion to the cord and nerve roots permitted only debulking.", + "Histopathological examination confirmed the diagnosis of tuberculoma.", + "The patient was started on antitubercular treatment.", + "After 8 months, the patient was reviewed and showed improvement in her symptoms.", + "The patient showed complete resolution of the lesion on imaging.", + "The patient has now developed hydrocephalus on the latest computed tomography imaging.", + "The hydrocephalus may be due to tubercular meningitis or arachnoiditis." + ] + }, + { + "id": "multiclinsum_test_1075_en.txt", + "fulltext": "We introduced a 34-year-old man with a definitive diagnosis of KS from two years ago, with a history of trauma to the ankle from 18 days ago. His family history of venous thromboembolism (VTE) was negative. He was hospitalized in the cardiology ward to treat chest pain and dyspnea, with the New York Heart Association Classification of Heart Failure (NYHA) class III. The clinical examination at the time of admission in OR exposed a drowsy patient with a history of twice syncope from the day before, palpitation (PR = 120), sweating, chest pain, blood pressure at 80/55 mmHg (with invasive blood pressure monitoring IBP), SpO2at 85% in ambient air and 92% under oxygen, and two-sided crackles on chest auscultation. In paraclinical findings, a D-dimer test was 1700 mg/mL, ECG revealed tachycardia with RBBB, transthoracic echocardiography presented a D-shape septum due to high RV pressure, moderate to severe RV enlargement, moderate to severe RV systolic dysfunction, hypertrabeculated RV apex, at least moderate TR, TRG = 40 mmHg, severe PAH, PAP = 55 mmHg, dilated IVC with respiratory variation < 50%, visible fresh cloth in main PA, and proximal part of branches in suprasternal view. On computed tomography angiography (CTA) of the lungs, a massive embolus was reported in the main pulmonary artery as well as in the right and left main branches. The troponin was negative. The lower extremities venous Doppler ultrasound revealed normal flow and no thrombosis. Because of this massive pulmonary embolism, the patient was a candidate for surgical embolectomy. After general anesthesia and placement on the hypothermic cardiopulmonary bypass (CPB) in the 28-degree centigrade, pulmonary embolectomy was done . After rewarming, weaning off from the CPB was easily done, without the need for inotrope. After four hours, the patient was extubated and weaning off the ventilator with a stable hemodynamic condition. The congestive signs were retreated well using diuretic treatment. The patient was discharged from the hospital in good general condition after one week with a warfarin prescription.", + "fulltext_subclaims": [ + "The patient is a 34-year-old man.", + "The patient has a definitive diagnosis of KS from two years ago.", + "The patient had trauma to the ankle 18 days ago.", + "The patient's family history of venous thromboembolism was negative.", + "The patient was hospitalized in the cardiology ward.", + "The patient had chest pain and dyspnea.", + "The patient's NYHA class was III.", + "The clinical examination at the time of admission in OR showed a drowsy patient.", + "The patient had a history of twice syncope from the day before.", + "The patient had palpitation with PR = 120.", + "The patient had sweating.", + "The patient had chest pain.", + "The patient's blood pressure was 80/55 mmHg with invasive blood pressure monitoring.", + "The patient's SpO2 was 85% in ambient air.", + "The patient's SpO2 was 92% under oxygen.", + "The patient had two-sided crackles on chest auscultation.", + "The D-dimer test was 1700 mg/mL.", + "The ECG revealed tachycardia with RBBB.", + "Transthoracic echocardiography showed a D-shape septum due to high RV pressure.", + "Transthoracic echocardiography showed moderate to severe RV enlargement.", + "Transthoracic echocardiography showed moderate to severe RV systolic dysfunction.", + "Transthoracic echocardiography showed a hypertrabeculated RV apex.", + "Transthoracic echocardiography showed at least moderate TR.", + "The TRG was 40 mmHg.", + "Transthoracic echocardiography showed severe PAH.", + "The PAP was 55 mmHg.", + "Transthoracic echocardiography showed a dilated IVC with respiratory variation < 50%.", + "Transthoracic echocardiography showed visible fresh cloth in main PA.", + "Transthoracic echocardiography showed visible fresh cloth in the proximal part of branches in suprasternal view.", + "CTA of the lungs reported a massive embolus in the main pulmonary artery.", + "CTA of the lungs reported a massive embolus in the right and left main branches.", + "The troponin was negative.", + "Venous Doppler ultrasound of the lower extremities showed normal flow.", + "Venous Doppler ultrasound of the lower extremities showed no thrombosis.", + "The patient was a candidate for surgical embolectomy.", + "The patient was placed on hypothermic cardiopulmonary bypass at 28 degrees centigrade.", + "Pulmonary embolectomy was done.", + "Weaning off from the CPB was easily done without the need for inotrope.", + "The patient was extubated after four hours.", + "The patient was weaned off the ventilator with a stable hemodynamic condition.", + "The congestive signs were retreated well using diuretic treatment.", + "The patient was discharged from the hospital after one week.", + "The patient was discharged with a warfarin prescription." + ], + "summary": "A 34-year-old male identified with a definitive diagnosis of KS was hospitalized to our cardiac surgery center through the emergency with chief complaints of acute chest pain and dyspnea. Saddle pulmonary thromboembolism was established from chest Computed Tomography Angiography (CTA). The patient's symptoms resolved after embolectomy via surgery.", + "summary_subclaims": [ + "A 34-year-old male identified with a definitive diagnosis of KS was hospitalized to our cardiac surgery center through the emergency with chief complaints of acute chest pain and dyspnea.", + "Saddle pulmonary thromboembolism was established from chest Computed Tomography Angiography (CTA).", + "The patient's symptoms resolved after embolectomy via surgery." + ] + }, + { + "id": "multiclinsum_test_2127_en.txt", + "fulltext": "A 23-year-old critically-ill male with history of Burkitt’s lymphoma, with graft-versus-host disease (GVHD) requiring high-dose corticosteroids, was admitted to the Emergency Department following a 2 days history of somnolence and confusion with evolving respiratory distress requiring endotracheal intubation. On admission neurological examination, he would open eyes to painful stimuli and continued to follow commands.\nInitial CT head revealed a flame hemorrhage in the left gyrus rectus suspicious for vascular origin and a hypodensity in the left thalamus suspicious for an established infarction. An angiogram performed the next day demonstrated six fusiform aneurysms: three at the frontopolar branch and one at the orbitofrontal branch of the left anterior cerebral artery (ACA); 1 at the frontopolar branch of the right ACA; and one at the anterior temporal artery of the left middle cerebral artery (MCA); . Body imaging revealed cavitary lung lesions. The patient was started on broad spectrum antibiotics, antifungals, and antiviral medications.\nThe location of hemorrhage pointed to the left ACA branch aneurysms as the source. Surgery was chosen to allow for inspection of all lesions under direct vision for ruptured status as well as obtain tissue for microbiological purposes. A bicoronal craniotomy, parent vessel sacrifice, and excision of the three aneurysms arising from the left ACA were performed on postbleed day 2. Intraoperatively, the aneurysms were friable, thin walled, and prone to bleeding. The right ACA aneurysms were managed conservatively. Microbiology confirmed angioinvasive S. apiospermum infection. Vericonazole, amphotericin B, and caspofunging were started empirically and continued throughout the disease process.\nCT scan obtained due to neurological deterioration on postbleed day 4 revealed new left frontal intracerebral hemorrhage and intraventricular hemorrhage (IVH). An emergency external ventricular drain was placed and a follow-up angiogram was obtained revealing interval growth of the left orbitofrontal artery aneurysm. Since microbiological diagnosis was available, endovascular parent vessel occlusion was recommended and preceded uneventfully. An interval angiogram on postbleed day 7 demonstrated three new fusiform aneurysms of the right ACA, a new aneurysm of the left anterior choroidal artery (AChA), and the left posterior communicating artery (PCOMA) and confirmed a stable appearing left anterior temporal artery aneurysm. Due to the rapid development of new aneurysms, as well as the hemorrhagic presentation, the treatment was recommended. A3–A3 revascularization was attempted to avoid ACA sacrifice; however, due to the friable nature of the diseased vessels, this was unsuccessful and parent vessel sacrifice had to be performed. An intraoperative angiogram demonstrated a new anterior communicating artery (ACOMA) aneurysm, which was left untreated at the time of surgery. On further follow-up imaging, the ACOMA aneurysm continued to enlarge and, therefore, was treated with endovascular A1 occlusions on postbleed day 9. Finally, continued surveillance imaging demonstrated interval growth of the previously identified left AChA and PCOMA aneurysm, which were ultimately treated with parent vessel sacrifice.\nDespite multiple parent vessel sacrifice, the patient recovered neurologically, continued to follow commands with upper extremities with expected, severe paraparesis in the lower extremities. His follow-up MRI confirmed a thalamic infarct which was already seen on admission imaging and new, incomplete ACA territory infarctions in keeping with the previous surgeries and parent vessel sacrifice of the bilateral ACAs. Due the severe systemic and pulmonary disease, the patient remained intubated and ventilated and underwent a tracheostomy procedure. His subsequent course was complicated with septic shock from multidrug resistant pseudomonas superinfection of the cavitary lung lesions and the patient died 6 months after the hemorrhagic presentation.", + "fulltext_subclaims": [ + "The patient was a 23-year-old critically-ill male.", + "He had a history of Burkitt’s lymphoma.", + "He had graft-versus-host disease requiring high-dose corticosteroids.", + "He was admitted after 2 days of somnolence and confusion.", + "He had evolving respiratory distress requiring endotracheal intubation.", + "On admission, he would open eyes to painful stimuli.", + "On admission, he continued to follow commands.", + "Initial CT head showed a flame hemorrhage in the left gyrus rectus.", + "The flame hemorrhage was suspicious for vascular origin.", + "A hypodensity in the left thalamus was suspicious for an established infarction.", + "An angiogram demonstrated six fusiform aneurysms.", + "Three aneurysms were at the frontopolar branch of the left anterior cerebral artery.", + "One aneurysm was at the orbitofrontal branch of the left anterior cerebral artery.", + "One aneurysm was at the frontopolar branch of the right anterior cerebral artery.", + "One aneurysm was at the anterior temporal artery of the left middle cerebral artery.", + "Body imaging revealed cavitary lung lesions.", + "The patient was started on broad spectrum antibiotics.", + "The patient was started on antifungals.", + "The patient was started on antiviral medications.", + "The location of hemorrhage pointed to the left ACA branch aneurysms as the source.", + "Surgery was chosen to allow for inspection of all lesions under direct vision.", + "Surgery was chosen to obtain tissue for microbiological purposes.", + "A bicoronal craniotomy, parent vessel sacrifice, and excision of the three aneurysms arising from the left ACA were performed on postbleed day 2.", + "Intraoperatively, the aneurysms were friable, thin walled, and prone to bleeding.", + "The right ACA aneurysms were managed conservatively.", + "Microbiology confirmed angioinvasive S. apiospermum infection.", + "Vericonazole, amphotericin B, and caspofunging were started empirically.", + "Vericonazole, amphotericin B, and caspofunging were continued throughout the disease process.", + "A CT scan on postbleed day 4 revealed new left frontal intracerebral hemorrhage.", + "A CT scan on postbleed day 4 revealed intraventricular hemorrhage.", + "An emergency external ventricular drain was placed.", + "A follow-up angiogram revealed interval growth of the left orbitofrontal artery aneurysm.", + "Endovascular parent vessel occlusion was recommended.", + "Endovascular parent vessel occlusion was performed uneventfully.", + "An interval angiogram on postbleed day 7 demonstrated three new fusiform aneurysms of the right ACA.", + "An interval angiogram on postbleed day 7 demonstrated a new aneurysm of the left anterior choroidal artery.", + "An interval angiogram on postbleed day 7 demonstrated a new aneurysm of the left posterior communicating artery.", + "The interval angiogram on postbleed day 7 confirmed a stable appearing left anterior temporal artery aneurysm.", + "A3–A3 revascularization was attempted to avoid ACA sacrifice.", + "A3–A3 revascularization was unsuccessful.", + "Parent vessel sacrifice had to be performed.", + "An intraoperative angiogram demonstrated a new anterior communicating artery aneurysm.", + "The ACOMA aneurysm was left untreated at the time of surgery.", + "On further follow-up imaging, the ACOMA aneurysm continued to enlarge.", + "The ACOMA aneurysm was treated with endovascular A1 occlusions on postbleed day 9.", + "Surveillance imaging demonstrated interval growth of the previously identified left AChA aneurysm.", + "The left AChA aneurysm was ultimately treated with parent vessel sacrifice.", + "Surveillance imaging demonstrated interval growth of the previously identified left PCOMA aneurysm.", + "The left PCOMA aneurysm was ultimately treated with parent vessel sacrifice.", + "Despite multiple parent vessel sacrifices, the patient recovered neurologically.", + "The patient continued to follow commands with upper extremities.", + "The patient had severe paraparesis in the lower extremities.", + "Follow-up MRI confirmed a thalamic infarct.", + "The thalamic infarct was already seen on admission imaging.", + "Follow-up MRI showed new, incomplete ACA territory infarctions.", + "The infarctions were in keeping with previous surgeries and parent vessel sacrifice of the bilateral ACAs.", + "The patient remained intubated and ventilated.", + "The patient underwent a tracheostomy procedure.", + "The patient had septic shock from multidrug resistant pseudomonas superinfection.", + "The patient died 6 months after the hemorrhagic presentation." + ], + "summary": "We report a case of a 23-year-old patient with Burkitt's lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis.", + "summary_subclaims": [ + "The patient was a 23-year-old with Burkitt's lymphoma and graft-versus-host disease.", + "The patient was admitted with intracerebral hemorrhage.", + "The patient had 12 anterior circulation aneurysms from disseminated Scedosporium infection.", + "The patient died 6 months later from multiorgan failure.", + "The notable feature of this case is the rapid angioinvasiveness of the infection.", + "New aneurysms formed within days of clear angiographic imaging.", + "There was an apparent lack of skull base osteomyelitis." + ] + }, + { + "id": "multiclinsum_test_1955_en.txt", + "fulltext": "A 4-year-old girl was admitted to Instituto de Pediatria e Puericultura Martagão Gesteira, Universidade Federal do Rio de Janeiro, Brazil, in March 2010, due to recurrent infections and severe neutropenia. The main clinical events and laboratory tests performed were summarized in a timeline of 12-year follow-up . At admission, peripheral blood (PB) analysis showed: hemoglobin 9.8 g/L, platelet count 234 × 109/L, and white blood cell count (WBC) 6.9 × 109/L with neutrophils count: 0.56 × 109/L. The bone marrow (BM) presented: hypocellularity with a granulocytic maturation arrest and micromegakaryocytes without fibrosis. BM immunophenotyping using the EuroFlow panel and settings showed granulocytic maturation blocked with the absence of CD10 expression in mature neutrophils, together with CD13 and CD64 overexpression in promyelocytes and in the whole granulocytic maturation, respectively. Further, both monocytes and neutrophils abnormally expressed CD56 . The cytogenetic analysis by G-banding and fluorescence in situ hybridization showed: 46,XX,t(3;8)(p26;q21)c [25] (A). The patient was classified as cMDS with low blasts (cMDS-LB) . Prophylactic antibiotic therapy with amoxicillin was initiated in May 2010. In April 2013, the patient had <100 neutrophils and started granulocyte colony-stimulating factor (GCSF), which sustains neutrophil levels. In 2014, the patient had clinical worsening with marked hypoplasia of all hematopoietic lineages, a decrease in G:E ratio (2:1) with megaloblastic changes in erythroid cells lineage, and the presence of micromegakaryocytes. Immunophenotyping showed: granulocytic and erythroid maturation blocked and excess of blasts (5.4%) featuring a cMDS with an increased blast (cMDS-IB). Progressively, clinical evolution had been getting worse with very severe neutropenia (<0.2 × 109/L) without response to GCSF. In 2018, the patient had granulocytic maturation with intense blockage, more erythroid cells, dysplastic megakaryocytes, and 8% of myeloid blasts, characterizing the progression of the disease. At this time, allogeneic hematopoietic stem cell transplantation (aHSCT) was indicated. Then, search in the family identified the father as a donor for aHSCT. Nevertheless, he also has the t(3;8)(p26;q21)c change. A search for an international donor found an unrelated donor, but he was not available. During this period, when we were at the peak of the COVID-19 pandemic, the patient began to show clinical improvement and the stabilization of the number of blast cells. Since 2020, the patient has had no clinical complications and continues to use G-CSF. The patient had the stabilization of the blast cells count through the sequential bone marrow’s analysis. Since 2020, the patient has had no clinical complications. In 2022, the hemogram showed: hemoglobin 12.4 g/L, platelet count 242 × 109 L, and WBC 4.47 × 109 L. The patient remained under observation and using G-CSF and clinical follow-up semi-annual. No changes in the BM analysis were in the scheme of “watching and waiting” for a possible HSCT.", + "fulltext_subclaims": [ + "A 4-year-old girl was admitted to Instituto de Pediatria e Puericultura Martagão Gesteira, Universidade Federal do Rio de Janeiro, Brazil, in March 2010.", + "The admission was due to recurrent infections and severe neutropenia.", + "At admission, peripheral blood analysis showed hemoglobin 9.8 g/L.", + "At admission, peripheral blood analysis showed platelet count 234 × 109/L.", + "At admission, peripheral blood analysis showed white blood cell count 6.9 × 109/L.", + "At admission, peripheral blood analysis showed neutrophils count 0.56 × 109/L.", + "Bone marrow presented hypocellularity with granulocytic maturation arrest.", + "Bone marrow showed micromegakaryocytes without fibrosis.", + "BM immunophenotyping showed granulocytic maturation blocked.", + "BM immunophenotyping showed absence of CD10 expression in mature neutrophils.", + "BM immunophenotyping showed CD13 overexpression in promyelocytes.", + "BM immunophenotyping showed CD64 overexpression in the whole granulocytic maturation.", + "Both monocytes and neutrophils abnormally expressed CD56.", + "Cytogenetic analysis showed 46,XX,t(3;8)(p26;q21)c [25].", + "The patient was classified as cMDS with low blasts.", + "Prophylactic antibiotic therapy with amoxicillin was initiated in May 2010.", + "In April 2013, the patient had <100 neutrophils and started granulocyte colony-stimulating factor.", + "In 2014, the patient had marked hypoplasia of all hematopoietic lineages.", + "In 2014, the patient had a decrease in G:E ratio to 2:1.", + "In 2014, erythroid cells showed megaloblastic changes.", + "In 2014, immunophenotyping showed granulocytic and erythroid maturation blocked.", + "In 2014, immunophenotyping showed 5.4% blasts, characterizing cMDS with increased blasts.", + "Progressively, clinical evolution worsened with very severe neutropenia (<0.2 × 109/L).", + "In 2018, granulocytic maturation showed intense blockage.", + "In 2018, there were more erythroid cells.", + "In 2018, there were dysplastic megakaryocytes.", + "In 2018, there were 8% myeloid blasts, characterizing disease progression.", + "In 2018, allogeneic hematopoietic stem cell transplantation was indicated.", + "The father was identified as a donor for aHSCT.", + "The father also has the t(3;8)(p26;q21)c change.", + "An international unrelated donor was found but was not available.", + "During the peak of the COVID-19 pandemic, the patient began to show clinical improvement.", + "During the peak of the COVID-19 pandemic, the number of blast cells stabilized.", + "Since 2020, the patient has had no clinical complications.", + "Since 2020, the patient continues to use G-CSF.", + "In 2022, the hemogram showed hemoglobin 12.4 g/L.", + "In 2022, the hemogram showed platelet count 242 × 109/L.", + "In 2022, the hemogram showed WBC 4.47 × 109/L.", + "The patient remained under observation and using G-CSF.", + "The patient had no changes in BM analysis in the scheme of 'watching and waiting' for possible HSCT." + ], + "summary": "A 4-year-old girl showed repeated infections and severe neutropenia. Bone marrow presented hypocellularity with dysplastic features. The patient had a t(3;8)(p26;q21)c identified by G-banding and FISH analysis. The family nucleus investigation identified the paternal origin of the chromosomal translocation. The NGS study identified ANKRD26 and SRP72 variants of maternal origin. CGH-array analysis detected alterations in PRSS3P2 and KANSL genes. Immunohistochemistry showed abnormal p53 expression during the MDS evolution.", + "summary_subclaims": [ + "The patient is a 4-year-old girl.", + "The patient showed repeated infections.", + "The patient had severe neutropenia.", + "Bone marrow presented hypocellularity.", + "Bone marrow showed dysplastic features.", + "The patient had a t(3;8)(p26;q21)c identified by G-banding.", + "The patient had a t(3;8)(p26;q21)c identified by FISH analysis.", + "The family nucleus investigation identified the paternal origin of the chromosomal translocation.", + "The NGS study identified ANKRD26 variants of maternal origin.", + "The NGS study identified SRP72 variants of maternal origin.", + "CGH-array analysis detected alterations in PRSS3P2.", + "CGH-array analysis detected alterations in KANSL.", + "Immunohistochemistry showed abnormal p53 expression during the MDS evolution." + ] + }, + { + "id": "multiclinsum_test_506_en.txt", + "fulltext": "A 43-year-old previously healthy man, a physician, living in a city of about 150,000 inhabitants, began to use a lightweight motorbike to commute to work, a distance of about 10 km, in heavy traffic in the middle of August 2006. He had previously been travelling in a car fitted with an air pollution filter, and had experienced no previous heart symptoms. He also walked or jogged about 6 km four to five times a week with no problems and was not on any medication. He felt relaxed and did not experience stress while riding the motorbike in heavy traffic. There were numerous traffic lights on his journey to work, which meant that he was forced to stop behind buses and trucks on several occasions where he experienced a strong smell of exhaust fumes.\nAfter commuting to and from work by motorbike for about 2 weeks he began experiencing cardiac extrasystoles, something not previously experienced; on one occasion he was unable to sleep due to palpitations. He sought help and had an electrocardiogram (ECG) the following morning, which showed PVCs in bigeminy. The patient had also sinus tachycardia with a heart rate of about 110 beats per minute.\nThe patient was admitted to the cardiac intensive care unit and was examined using echocardiography, which was found to be normal, and there were no signs of false tendons. No ischaemia was seen on ECG and there were no signs of infarction. The frequency of PVCs began to decrease about 8 hours after admission. Blood tests showed no indications of infarction or infection, his blood glucose was normal and his lipid status and thyroid status were within normal limits. The patient had no fever. During the night and the next morning only a few PVCs and some premature atrial complexes were observed and the patient was discharged home. The diagnosis was given as myocarditis, although this diagnosis was uncertain.\nThe patient rested for 2 weeks with no further symptoms before returning to work. For the first few weeks he drove his car to work, but then began to use his motorbike again. Having used it for a few weeks on the same route he again began to experience extrasystoles and therefore contacted his physician, who recommended an exercise test and Holter ECG.\nIn the few days before the Holter ECG was applied the patient refrained from using his motorbike and began to feel better. Only a few PVCs and premature atrial complexes were found during 24 hours of Holter monitoring. The heart rate variability (HRV) showed a pattern with a somewhat high low-frequency to high-frequency ratio. An exercise test was carried out and the patient performed well, with no chest pain, arrhythmias or signs of ischaemia.\nThe patient began to believe that there was an association between using his motorbike and his symptoms and decided to stop using it. Since then no symptoms, apart from an occasional single extrasystole, have been noted by the patient.", + "fulltext_subclaims": [ + "The patient is a 43-year-old previously healthy man.", + "He is a physician.", + "He lives in a city of about 150,000 inhabitants.", + "He began to use a lightweight motorbike to commute to work in heavy traffic in the middle of August 2006.", + "He had previously been travelling in a car fitted with an air pollution filter.", + "He had experienced no previous heart symptoms.", + "He walked or jogged about 6 km four to five times a week with no problems.", + "He was not on any medication.", + "He felt relaxed and did not experience stress while riding the motorbike in heavy traffic.", + "There were numerous traffic lights on his journey to work.", + "He was forced to stop behind buses and trucks on several occasions.", + "He experienced a strong smell of exhaust fumes.", + "After commuting to and from work by motorbike for about 2 weeks he began experiencing cardiac extrasystoles.", + "He had an electrocardiogram (ECG) the following morning.", + "The ECG showed PVCs in bigeminy.", + "The patient had sinus tachycardia with a heart rate of about 110 beats per minute.", + "The patient was admitted to the cardiac intensive care unit.", + "Echocardiography was found to be normal.", + "There were no signs of false tendons.", + "No ischaemia was seen on ECG.", + "There were no signs of infarction.", + "The frequency of PVCs began to decrease about 8 hours after admission.", + "Blood tests showed no indications of infarction or infection.", + "His blood glucose was normal.", + "His lipid status and thyroid status were within normal limits.", + "The patient had no fever.", + "During the night and the next morning only a few PVCs and some premature atrial complexes were observed.", + "The patient was discharged home.", + "The diagnosis was given as myocarditis.", + "The diagnosis was uncertain.", + "The patient rested for 2 weeks with no further symptoms before returning to work.", + "For the first few weeks he drove his car to work.", + "He then began to use his motorbike again.", + "Having used it for a few weeks on the same route he again began to experience extrasystoles.", + "He contacted his physician.", + "His physician recommended an exercise test and Holter ECG.", + "In the few days before the Holter ECG was applied the patient refrained from using his motorbike.", + "He began to feel better.", + "Only a few PVCs and premature atrial complexes were found during 24 hours of Holter monitoring.", + "The heart rate variability showed a pattern with a somewhat high low-frequency to high-frequency ratio.", + "An exercise test was carried out.", + "The patient performed well.", + "There were no chest pain, arrhythmias or signs of ischaemia.", + "The patient began to believe that there was an association between using his motorbike and his symptoms.", + "He decided to stop using it.", + "Since then no symptoms, apart from an occasional single extrasystole, have been noted by the patient." + ], + "summary": "A previously healthy man started to ride a lightweight motorbike in heavy traffic. A few weeks later he was admitted to hospital with premature ventricular complexes in bigeminy, which decreased after a few days when he was not exposed to exhaust fumes. A few weeks later he started using the motorbike again and the same symptoms developed once more, only to subside when he stopped riding in heavy traffic.", + "summary_subclaims": [ + "A previously healthy man started to ride a lightweight motorbike in heavy traffic.", + "A few weeks later he was admitted to hospital with premature ventricular complexes in bigeminy.", + "The premature ventricular complexes decreased after a few days when he was not exposed to exhaust fumes.", + "A few weeks later he started using the motorbike again.", + "The same symptoms developed once more.", + "The symptoms subsided when he stopped riding in heavy traffic." + ] + }, + { + "id": "multiclinsum_test_2234_en.txt", + "fulltext": "An 8-year-old male patient presented to the emergency department after a history of falling from height (3 m). On examination, the patient was well with mild abdominal pain and contusions in the upper and lower extremities. A focused assessment with sonography for trauma (FAST) was negative and serial complete blood counts (CBC) showed no drop in hemoglobin. The abdominal ultrasound performed the following day showed no intraabdominal fluid collections and the abdominal pain disappeared, so he was discharged in a good condition.\nSix weeks later, the patient presented to the emergency department complaining of pain in the right lower abdomen for two days’ duration. The pain increased gradually and was associated with fever (38.5 °C), anorexia, nausea, and vomiting; however, he had no trouble in passing stools and flatus. Otherwise, the vital signs were within normal. On examination, the patient looked ill and irritable. The abdomen was flat on shape with localized tenderness in the right iliac fossa. Rebound tenderness in the right lower quadrant was positive. Rigidity and guarding were not found, and examination of the genitalia was normal. The patient and his family don’t have any history of a bleeding disorder, and he is free of medications.\nLaboratory investigations showed leukocytosis of 13,000 cells/mm3 with a neutrophil predominance (73 %), normal Hb level (13.8 g/dl), and normal urine analysis. Abdominal ultrasound showed a poorly visualized appendix.\nAt this point, the clinical differential diagnosis was acute appendicitis, and the patient was prepared for urgent appendectomy through a Gridiron incision. Intraoperatively, a subserosal cecal hematoma 10 × 8 cm extending from the antimesenteric to the mesenteric border of the cecum was found . The hematoma was not expandable or pulsatile and there was no extension to the ascending colon with the appendix grossly appeared normal. Appendectomy was performed and the cecal hematoma was evacuated, which showed dark blood with, many clots . After ensuring that there was no oozing following the evacuation, interrupted repair of the cecal seromuscular layer by vicryl 3-0 was executed and a pelvic drain was applied.\nPostoperatively, the patient was kept NPO for three days; so, intravenous fluid, parenteral ciprofloxacin, and metronidazole were given and also Pethidine when needed. On a postoperative day 2 (POD-2), the patient passed flatus. At POD-3, he was given sips of water and he tolerated them well, so oral intake was started gradually. At POD-5, the patient passed stool and the abdominal ultrasound was normal with no fluid collection. Then, he was discharged with no symptoms. Follow-up for the patient at POD 10 with history, exam, and abdominal ultrasound was normal. The patient had several follow-ups for two years and he was in good condition, without complications or recurrence.", + "fulltext_subclaims": [ + "An 8-year-old male patient presented to the emergency department after a history of falling from height (3 m).", + "On examination, the patient was well with mild abdominal pain and contusions in the upper and lower extremities.", + "A focused assessment with sonography for trauma (FAST) was negative.", + "Serial complete blood counts (CBC) showed no drop in hemoglobin.", + "The abdominal ultrasound performed the following day showed no intraabdominal fluid collections.", + "The abdominal pain disappeared.", + "He was discharged in a good condition.", + "Six weeks later, the patient presented to the emergency department complaining of pain in the right lower abdomen for two days’ duration.", + "The pain increased gradually and was associated with fever (38.5 °C), anorexia, nausea, and vomiting.", + "He had no trouble in passing stools and flatus.", + "Otherwise, the vital signs were within normal.", + "On examination, the patient looked ill and irritable.", + "The abdomen was flat on shape with localized tenderness in the right iliac fossa.", + "Rebound tenderness in the right lower quadrant was positive.", + "Rigidity and guarding were not found.", + "Examination of the genitalia was normal.", + "The patient and his family don’t have any history of a bleeding disorder.", + "He is free of medications.", + "Laboratory investigations showed leukocytosis of 13,000 cells/mm3 with a neutrophil predominance (73 %).", + "Hb level was normal (13.8 g/dl).", + "Urine analysis was normal.", + "Abdominal ultrasound showed a poorly visualized appendix.", + "The clinical differential diagnosis was acute appendicitis.", + "The patient was prepared for urgent appendectomy through a Gridiron incision.", + "Intraoperatively, a subserosal cecal hematoma 10 × 8 cm extending from the antimesenteric to the mesenteric border of the cecum was found.", + "The hematoma was not expandable or pulsatile.", + "There was no extension to the ascending colon.", + "The appendix grossly appeared normal.", + "Appendectomy was performed.", + "The cecal hematoma was evacuated, which showed dark blood with many clots.", + "After ensuring that there was no oozing following the evacuation, interrupted repair of the cecal seromuscular layer by vicryl 3-0 was executed.", + "A pelvic drain was applied.", + "Postoperatively, the patient was kept NPO for three days.", + "Intravenous fluid, parenteral ciprofloxacin, and metronidazole were given.", + "Pethidine was given when needed.", + "On a postoperative day 2 (POD-2), the patient passed flatus.", + "At POD-3, he was given sips of water and he tolerated them well, so oral intake was started gradually.", + "At POD-5, the patient passed stool and the abdominal ultrasound was normal with no fluid collection.", + "Then, he was discharged with no symptoms.", + "Follow-up for the patient at POD 10 with history, exam, and abdominal ultrasound was normal.", + "The patient had several follow-ups for two years and he was in good condition, without complications or recurrence." + ], + "summary": "Herein we describe an 8-year-old male patient who presented to the emergency department with an appendicitis-like picture six weeks after a history of falling. Intraoperatively, the patient was found to have a normal appendix. However, a large intramural cecal hematoma contains black blood with many clots was found. The patient was treated by hematoma evacuation with preservation of the cecum and colon and he was discharged with uneventful recovery. During two years follow up there was no history of complications or recurrence.", + "summary_subclaims": [ + "The patient is an 8-year-old male.", + "The patient presented to the emergency department with an appendicitis-like picture.", + "The appendicitis-like presentation occurred six weeks after a history of falling.", + "Intraoperatively, the patient was found to have a normal appendix.", + "A large intramural cecal hematoma containing black blood with many clots was found.", + "The patient was treated by hematoma evacuation.", + "The cecum and colon were preserved during the procedure.", + "The patient was discharged with uneventful recovery.", + "During two years of follow up, there was no history of complications.", + "During two years of follow up, there was no history of recurrence." + ] + }, + { + "id": "multiclinsum_test_2805_en.txt", + "fulltext": "A 73-year-old male (174 cm, 47 kg) with the American Society of Anesthesiologist physical classification of 3 was scheduled for elective left nephroureterectomy. A left calyx tumor was incidentally discovered during a routine medical examination, and a biopsy performed 1 month ago during ureteroscopy suggested a urothelial carcinoma. Past medical history includes intraductal papillary mucinous neoplasm of the liver that was surgically removed 6 years ago. A preoperative evaluation was performed, and chest computed tomography (CT) revealed pulmonary thromboembolism in the left lower lobe. A lower extremity ultrasonogram showed no evidence of deep vein thrombosis, and arterial blood gas analysis and D-dimer were within the normal ranges. The patient was instructed to fast for 8 hours (nothing by mouth) before undergoing general anesthesia. Premedication involved administrating an intramuscular injection of glycopyrrolate (0.2 mg) and famotidine (20 mg). In the operating room, noninvasive monitoring devices were placed on the patient, including a blood pressure cuff, electrocardiogram, a pulse oximeter, a bispectral index signal device, and a quantitative monitor for neuromuscular blockade. General anesthesia was induced using 80 mg propofol, followed by 30 mg rocuronium for neuromuscular blockade after confirming no response to stimuli. Then, sevoflurane (1.7%) was used to maintain the appropriate anesthesia depth after intubation. Because of the risk of bleeding from renal artery surgery, an arterial line was inserted into the right radial artery. Furthermore, right internal jugular vein central venous catheterization was planned. Real-time ultrasound-guided catheterization was initially planned; however, the hospital’s portable ultrasonography device was in use in other operating rooms; therefore, a blind catheterization technique was used based on the patient’s anatomical structure without ultrasound guidance. The patient was positioned in the Trendelenburg position with the head 15° below the horizontal plane and tilted 40° to the left. The Bermuda triangle, an anatomical structure formed by the posterior margin of the sternal muscle belly of the sternocleidomastoid muscle, the anterior margin of the clavicular muscle belly, and the upper margin of the clavicle, was clearly identified. The carotid artery pulse was palpated at the superior angle of the triangle and followed to the center of the triangle, where a 10 ml syringe connected to a 23-gauge finder needle was inserted perpendicularly to the surface while aspirating. The presence of dark venous blood was confirmed at a depth of 2.2 cm, and no pulsation was observed after separating the finder needle from the syringe. Then, the 18-gauge puncture needle connected to the syringe was inserted toward the nipple at a 75° angle from the skin while targeting the finder needle tip, and the aspiration of venous blood flow was confirmed. After removing the finder needle, a guidewire was inserted to a depth of 20 cm from the skin through the puncture needle without any resistance felt during the procedure. The puncture needle was removed while leaving the guidewire in place. Prior to inserting the dilator, the practitioner and colleagues, experiencing a sense of unease during the procedure, attempted to investigate the anatomy of the puncture site by utilizing ultrasonography to detect the previously inserted guide wire, prompted by their concern that the depth of the finder needle, measuring 2.2 cm, is deeper than observed in other patients, which contributed to their uneasiness. The guidewire was found to be located in a vein as which we presumed the vessel based on its location that was lateral from the common carotid artery and collapsibility when pressure was applied using the probe. However, a larger vessel presumed to be a vein was located superiorly and more laterally than the identified vessel. Real-time ultrasound-guided guidewire insertion was performed at the same view in this vessel using another central venous catheter kit. Both guidewires were left in place while the probe was tilted to visualize their paths, and it was confirmed that they were both descending toward the right brachiocephalic vein . The first guidewire was removed, and manual compression using sterile gauze was applied for over 5 min. No resistance was felt during the removal. The second guidewire was used to complete the central venous catheterization, and free regurgitation was observed at each port. The central venous pressure (CVP) measured using the central venous catheter was 15 mmHg. The surgery was successful, and the patient was transferred to the post-anesthesia care unit after extubation. A simple anterior-to-posterior chest X-ray (CXR) taken immediately after the surgery confirmed that the catheter tip was located near the right atrium, following the superior vena cava (SVC) . We reviewed the contrast-enhanced chest CT performed for preoperative evaluation and confirmed that the right internal jugular vein coursed laterally to the right common carotid artery on the axial view. A large vessel was also observed behind the common carotid artery and internal jugular vein, and it was traced upward and downward, confirming that it enters into the transverse foramen at the level of the sixth cervical vertebra and drains into the right brachiocephalic vein, consistent with the known course of the cervical vertebral vein. The same findings were observed in the coronary view . The radiologist indicated this vessel as the vertebral vein. After considering the ultrasonographic findings and the radiologist’s official reading, we confirmed that the vein that we had initially punctured was indeed the right cervical vertebral vein. On the third day after surgery, the central venous catheter was removed, and the patient did not exhibit any complications, such as bleeding, swelling, and neurological symptoms.", + "fulltext_subclaims": [ + "The patient was a 73-year-old male.", + "The patient was 174 cm tall and weighed 47 kg.", + "The patient had an American Society of Anesthesiologists physical classification of 3.", + "The patient was scheduled for elective left nephroureterectomy.", + "A left calyx tumor was incidentally discovered during a routine medical examination.", + "A biopsy performed 1 month ago during ureteroscopy suggested a urothelial carcinoma.", + "The patient had a past medical history of intraductal papillary mucinous neoplasm of the liver that was surgically removed 6 years ago.", + "Chest computed tomography (CT) revealed pulmonary thromboembolism in the left lower lobe.", + "A lower extremity ultrasonogram showed no evidence of deep vein thrombosis.", + "Arterial blood gas analysis and D-dimer were within the normal ranges.", + "The patient was instructed to fast for 8 hours before undergoing general anesthesia.", + "Premedication involved an intramuscular injection of glycopyrrolate (0.2 mg) and famotidine (20 mg).", + "Noninvasive monitoring devices were placed on the patient, including a blood pressure cuff, electrocardiogram, a pulse oximeter, a bispectral index signal device, and a quantitative monitor for neuromuscular blockade.", + "General anesthesia was induced using 80 mg propofol.", + "Rocuronium (30 mg) was used for neuromuscular blockade after confirming no response to stimuli.", + "Sevoflurane (1.7%) was used to maintain the appropriate anesthesia depth after intubation.", + "An arterial line was inserted into the right radial artery.", + "Right internal jugular vein central venous catheterization was planned.", + "Real-time ultrasound-guided catheterization was initially planned.", + "The hospital’s portable ultrasonography device was in use in other operating rooms.", + "A blind catheterization technique was used based on the patient’s anatomical structure without ultrasound guidance.", + "The patient was positioned in the Trendelenburg position with the head 15° below the horizontal plane and tilted 40° to the left.", + "The Bermuda triangle was clearly identified.", + "The carotid artery pulse was palpated at the superior angle of the triangle and followed to the center of the triangle.", + "A 10 ml syringe connected to a 23-gauge finder needle was inserted perpendicularly to the surface while aspirating.", + "The presence of dark venous blood was confirmed at a depth of 2.2 cm.", + "No pulsation was observed after separating the finder needle from the syringe.", + "An 18-gauge puncture needle connected to the syringe was inserted toward the nipple at a 75° angle from the skin while targeting the finder needle tip.", + "The aspiration of venous blood flow was confirmed.", + "A guidewire was inserted to a depth of 20 cm from the skin through the puncture needle without any resistance felt during the procedure.", + "The puncture needle was removed while leaving the guidewire in place.", + "The practitioner and colleagues attempted to investigate the anatomy of the puncture site by utilizing ultrasonography to detect the previously inserted guidewire.", + "The guidewire was found to be located in a vein as which we presumed the vessel based on its location that was lateral from the common carotid artery and collapsibility when pressure was applied using the probe.", + "A larger vessel presumed to be a vein was located superiorly and more laterally than the identified vessel.", + "Real-time ultrasound-guided guidewire insertion was performed at the same view in this vessel using another central venous catheter kit.", + "Both guidewires were left in place while the probe was tilted to visualize their paths.", + "It was confirmed that they were both descending toward the right brachiocephalic vein.", + "The first guidewire was removed, and manual compression using sterile gauze was applied for over 5 min.", + "No resistance was felt during the removal.", + "The second guidewire was used to complete the central venous catheterization.", + "Free regurgitation was observed at each port.", + "The central venous pressure measured using the central venous catheter was 15 mmHg.", + "The surgery was successful.", + "The patient was transferred to the post-anesthesia care unit after extubation.", + "A simple anterior-to-posterior chest X-ray taken immediately after the surgery confirmed that the catheter tip was located near the right atrium, following the superior vena cava.", + "We reviewed the contrast-enhanced chest CT performed for preoperative evaluation and confirmed that the right internal jugular vein coursed laterally to the right common carotid artery on the axial view.", + "A large vessel was also observed behind the common carotid artery and internal jugular vein.", + "It was traced upward and downward, confirming that it enters into the transverse foramen at the level of the sixth cervical vertebra and drains into the right brachiocephalic vein.", + "The same findings were observed in the coronary view.", + "The radiologist indicated this vessel as the vertebral vein.", + "After considering the ultrasonographic findings and the radiologist’s official reading, we confirmed that the vein that we had initially punctured was indeed the right cervical vertebral vein.", + "On the third day after surgery, the central venous catheter was removed.", + "The patient did not exhibit any complications, such as bleeding, swelling, and neurological symptoms." + ], + "summary": "A 73-year-old male suspected to have a urothelial carcinoma was scheduled for elective left nephroureterectomy. During central venous catheterization using the anatomic landmark technique to target the internal jugular vein, a guidewire is inadvertently inserted into the suspected vertebral vein. Following the correction of the catheterization, a radiologist reviewed the preoperative enhanced computed tomography and confirmed that the initially punctured vessel was the vertebral vein. On the third day after surgery, the central venous catheter was removed, and the patient did not exhibit any complications, such as bleeding, swelling, and neurological symptoms.", + "summary_subclaims": [ + "The patient was a 73-year-old male.", + "The patient was suspected to have a urothelial carcinoma.", + "The patient was scheduled for elective left nephroureterectomy.", + "During central venous catheterization, the anatomic landmark technique was used to target the internal jugular vein.", + "A guidewire was inadvertently inserted into the suspected vertebral vein.", + "The radiologist reviewed the preoperative enhanced computed tomography.", + "The radiologist confirmed that the initially punctured vessel was the vertebral vein.", + "The central venous catheter was removed on the third day after surgery.", + "The patient did not exhibit any complications, such as bleeding, swelling, and neurological symptoms." + ] + }, + { + "id": "multiclinsum_test_74_en.txt", + "fulltext": "A duodenal mass that had been discovered 2 mo previously\nA 47-year-old man was admitted to our hospital on November 20, 2015 because of a duodenal mass that had been discovered 2 mo previously. Electronic gastroscopy at another hospital revealed a duodenal papillary mass that had been considered to be a high-grade intraepithelial neoplasia and was left untreated. The patient reported having no significant, recent weight loss. We carried out relevant examinations, confirmed the diagnosis, and took further treatment measures.\nThe patient was healthy before.\nThe patient and families were healthy before.\nThe patient’s vital signs were: Temperature, 36.2 ℃; pulse rate, 75 bpm; respiratory rate, 20 breaths/min; and blood pressure, 110/70 mmHg. The physical examination revealed a normal countenance; absence of superficial lymph node enlargement and heart abnormalities; a flat abdomen; liver and spleen not palpated below the costal margin; hypogastric region tenderness; no shifting dullness absent; bowel sounds of 4 times/min, with no increase or decrease; and gurgles and abdominal vascular murmurs not audible.\nLaboratory test results included: White blood cell count, 4.5 × 109/L; erythrocyte count, 4.42 × 1012/L; hemoglobin, 144 g/L; platelet count, 130 × 109/L; normal liver and kidney function; prothrombin time, 14 s; fibrinogen, 3.09 g/L; tumor marker CA-125, 7.19 U/mL (normal < 35 U/mL); CA-199, 7.07 U/mL (normal < 37 U/mL); alpha-fetoprotein, 3.17 ng/mL (normal 0.89-8.78 ng/mL); and CEA, 1.67 ng/mL (normal < 5 ng/mL). The rest of the parameters were within the normal range.\nAbdominal computed tomography showed a space-occupying lesion at the head of the pancreas and the duodenal bulb . Due to the aforementioned imaging findings, a preliminary diagnosis of a duodenal papillary space-occupying lesion was made.\nTwo days before the operation, the patient was fed a liquid diet. After fasting for 8 h before surgery, an intravenous injection of 2 g cefazoxime sodium was given 30 min before surgery to prevent infection. A patient-controlled analgesia pump was provided postoperatively. The patient was treated by hemostasis, nutrition, and water and electrolyte supplementation. Routine blood and biochemical indexes were monitored.\nAfter general anesthesia, the patient was placed in a supine position, and then disinfected and trocar inserted. A laparoscopic exploration was then performed. As the gallbladder wall tension was not increased, the hepatoduodenal lymph nodes were not significantly enlarged, and there were no other significant findings in the peritoneal and pelvic cavities, we decided to perform a pancreas-preserving duodenectomy with a median abdominal incision. The gastrocolic ligament was opened to expose the duodenum, which was dissociated along the upper edge of the duodenum until the ligament of Treitz. The branch vessels entering the upper end of the duodenal bulb and the pancreas were ligated using USP 0 sutures. On turning the descending part of duodenum to the right and freeing the common bile duct and pancreatic duct on the inner side of the descending part of the duodenum , a 3 cm × 3 cm solid mass with a hard, firm texture was palpable. The mass was not found to involve the pancreas and hepatoduodenal ligament. The common bile duct was freed along the duodenal papilla upward, until no significant mass invasion could be found. The common bile duct was severed at the pancreas side and the pancreatic duct was freed from the head of the pancreas toward the inner side until no significant mass invasion was found. After the distal part of the stomach, duodenum, and the tissues surrounding the pancreas were freed, the stomach was transected 6 cm from the pylorus using an endoscopic linear cutter and the jejunum was also transected 5 cm under the ligament of Treitz using a 6-0 linear cutter. After removing the specimen, the distal part of the jejunum was lifted from behind the colon to the level of the porta hepatis. An incision with a length equivalent to the opening of the bile duct was made on the contralateral edge of the mesojejunum, 5 cm from the jejunal stump. Bilioenteric anastomosis was performed through full-thickness continuous sutures using 6-0 prolene sutures. The residual pancreatic body and tail were freed and lifted for placement of an infusion tube scalp needle with an opening on the side. The main pancreatic duct and jejunal mucosa were continuously sutured using 5-0 proline sutures, and the head of the pancreas and the seromuscular layer of the jejunum were sutured in an interrupted manner, using USP 0 sutures. A Frankenman 25 stapler was used for Billroth I in situ anastomosis between the pyloric part and the jejunum, and the serous layer at the anastomosis site was sutured using USP 0 sutures . The operation was successful and the tumor was completely removed. The operative time was 295 min, and the intraoperative blood loss was 100 mL. There were no obvious postoperative complications, and the patient was discharged 14 d after the operation.\nThe macroscopic examination of the surgical specimen showed a cancerous tumor with a white-gray color and a hard texture in the duodenal papilla . A pathological diagnosis of adenocarcinoma of the duodenal papilla with infiltration in the full thickness of the intestinal wall was made. The stumps of the pancreatic duct and bile duct and the lymph nodes were negative and thus an R0 resection was achieved. No atypical cells were found in the pancreatic tissues surrounding the pancreatic duct and bile duct (pT2N0M0).\nA patient-controlled analgesia pump was provided postoperatively. The patient was treated by hemostasis, nutrition, and water and electrolyte supplementation. Routine blood and biochemical indexes were monitored. The patient refused to receive chemotherapy, and no obvious abnormalities were found in relevant examinations.", + "fulltext_subclaims": [ + "A 47-year-old man was admitted to our hospital on November 20, 2015.", + "The patient had a duodenal mass that had been discovered 2 mo previously.", + "Electronic gastroscopy at another hospital revealed a duodenal papillary mass.", + "The mass had been considered to be a high-grade intraepithelial neoplasia.", + "The mass was left untreated.", + "The patient reported having no significant, recent weight loss.", + "We carried out relevant examinations.", + "We confirmed the diagnosis.", + "We took further treatment measures.", + "The patient was healthy before.", + "The patient’s vital signs were: Temperature, 36.2 ℃; pulse rate, 75 bpm; respiratory rate, 20 breaths/min; and blood pressure, 110/70 mmHg.", + "The physical examination revealed a normal countenance.", + "There was absence of superficial lymph node enlargement.", + "There were no heart abnormalities.", + "The abdomen was flat.", + "The liver and spleen were not palpated below the costal margin.", + "There was hypogastric region tenderness.", + "There was no shifting dullness.", + "Bowel sounds were 4 times/min.", + "Gurgles and abdominal vascular murmurs were not audible.", + "The white blood cell count was 4.5 × 109/L.", + "The erythrocyte count was 4.42 × 1012/L.", + "The hemoglobin was 144 g/L.", + "The platelet count was 130 × 109/L.", + "Liver and kidney function were normal.", + "The prothrombin time was 14 s.", + "The fibrinogen was 3.09 g/L.", + "The tumor marker CA-125 was 7.19 U/mL.", + "The tumor marker CA-199 was 7.07 U/mL.", + "The alpha-fetoprotein was 3.17 ng/mL.", + "The CEA was 1.67 ng/mL.", + "Abdominal computed tomography showed a space-occupying lesion at the head of the pancreas and the duodenal bulb.", + "A preliminary diagnosis of a duodenal papillary space-occupying lesion was made.", + "Two days before the operation, the patient was fed a liquid diet.", + "An intravenous injection of 2 g cefazoxime sodium was given 30 min before surgery.", + "A patient-controlled analgesia pump was provided postoperatively.", + "The patient was treated by hemostasis, nutrition, and water and electrolyte supplementation.", + "Routine blood and biochemical indexes were monitored.", + "After general anesthesia, the patient was placed in a supine position.", + "A laparoscopic exploration was performed.", + "The gallbladder wall tension was not increased.", + "The hepatoduodenal lymph nodes were not significantly enlarged.", + "There were no other significant findings in the peritoneal and pelvic cavities.", + "A pancreas-preserving duodenectomy with a median abdominal incision was performed.", + "The gastrocolic ligament was opened to expose the duodenum.", + "The duodenum was dissociated along the upper edge until the ligament of Treitz.", + "The branch vessels entering the upper end of the duodenal bulb and the pancreas were ligated using USP 0 sutures.", + "A 3 cm × 3 cm solid mass with a hard, firm texture was palpable.", + "The mass was not found to involve the pancreas.", + "The mass was not found to involve the hepatoduodenal ligament.", + "The common bile duct was severed at the pancreas side.", + "The pancreatic duct was freed from the head of the pancreas toward the inner side.", + "The distal part of the stomach was transected 6 cm from the pylorus using an endoscopic linear cutter.", + "The jejunum was transected 5 cm under the ligament of Treitz using a 6-0 linear cutter.", + "Bilioenteric anastomosis was performed through full-thickness continuous sutures using 6-0 prolene sutures.", + "The main pancreatic duct and jejunal mucosa were continuously sutured using 5-0 proline sutures.", + "The head of the pancreas and the seromuscular layer of the jejunum were sutured in an interrupted manner, using USP 0 sutures.", + "A Frankenman 25 stapler was used for Billroth I in situ anastomosis between the pyloric part and the jejunum.", + "The serous layer at the anastomosis site was sutured using USP 0 sutures.", + "The operation was successful.", + "The tumor was completely removed.", + "The operative time was 295 min.", + "The intraoperative blood loss was 100 mL.", + "There were no obvious postoperative complications.", + "The patient was discharged 14 d after the operation.", + "The macroscopic examination of the surgical specimen showed a cancerous tumor with a white-gray color and a hard texture in the duodenal papilla.", + "A pathological diagnosis of adenocarcinoma of the duodenal papilla with infiltration in the full thickness of the intestinal wall was made.", + "The stumps of the pancreatic duct and bile duct and the lymph nodes were negative.", + "An R0 resection was achieved.", + "No atypical cells were found in the pancreatic tissues surrounding the pancreatic duct and bile duct.", + "The patient refused to receive chemotherapy.", + "No obvious abnormalities were found in relevant examinations." + ], + "summary": "A 47-year-old man was admitted to because of a duodenal mass that had been discovered 2 mo previously. Electronic gastroscopy at another hospital revealed a duodenal papillary mass that had been considered to be a high-grade intraepithelial neoplasia. Therefore, we conducted a multidisciplinary group discussion and decided to perform a pancreas-preserving duodenectomy and a R0 resection was successfully performed. After surgery, the patient underwent a follow-up period of 5 yr. No recurrence or metastasis occurred.", + "summary_subclaims": [ + "The patient was a 47-year-old man.", + "He was admitted because of a duodenal mass discovered 2 mo previously.", + "Electronic gastroscopy at another hospital revealed a duodenal papillary mass.", + "The mass had been considered to be a high-grade intraepithelial neoplasia.", + "A multidisciplinary group discussion was conducted.", + "A pancreas-preserving duodenectomy was decided.", + "A R0 resection was successfully performed.", + "The patient underwent a follow-up period of 5 yr.", + "No recurrence occurred.", + "No metastasis occurred." + ] + }, + { + "id": "multiclinsum_test_2036_en.txt", + "fulltext": "Our patient was a 19-year-old woman who was the restrained driver in a roll-over accident at highway speed. Her Glasgow coma scale was 4 with extensor posturing. She was sedated, paralyzed, intubated, and transported to our hospital as a level 1 trauma. Her medical history was unremarkable.\nCT imaging of the head revealed multiple punctate hemorrhagic lesions, early effacement of the gray-white junction and diffuse traumatic subarachnoid hemorrhage .\nAn intraparenchymal ICP monitor was placed with initial readings of 23–25 mmHg. Supportive care was instituted with midline placement of the head and elevation of the head to 30°, sedation with propofol and analgesia with fentanyl. She required bolus doses of 20% mannitol for ICP surges with physical stimulation. On hospital day 3 she developed refractory intracranial hypertension and fever which persisted through hospital day 12 despite aggressive medical management. She was very sensitive to any physical stimulation, particularly changes in position or tracheal suctioning which resulted in ICP spikes. Osmotic therapy including alternating boluses of 20% mannitol and 23% saline were used to treat ICP surges. Maintenance fluids were changed to 3% saline solution in order to induce mild hypernatremia and decrease the need for rescue osmotic therapy. We induced mild hypothermia (35°C) using the Arctic Sun device (Bard, Inc., Atlanta, GA, USA) as an adjuvant to osmotic therapy with pharmacological neuromuscular paralysis to control the shivering response. Several attempts at reducing the degree of metabolic suppression by slowly increasing the core body temperature and lightening the degree of neuromuscular paralysis and propofol requirement failed. She consistently required a temperature under 35°C and a dose of Propofol greater than 40 mcg/kg/min to maintain control of her ICP. A repeat CT scan on hospital day 11 did not show significant cerebral edema to explain the persistent and refractory intracranial hypertension. It was noted that despite adequate hydration and apparent intravascular euvolemia, she was consistently tachycardic with intermittent periods of hypertension. This raised the possibility of sympathetic hyperactivity for which she was started on propranolol with only marginal decrease in the heart rate. On hospital day 12 a bolus of 4 mg of morphine was administered following a rise in ICP to 30 mmHg in an effort to determine if the elevation in ICP was due to a sympathetic surge. Immediately following the administration of morphine the ICP rose steadily from a baseline of 30 mmHg up to 55 mmHg over 3 min without any appreciable change in heart rate or blood pressure. The transient but significant rise in ICP was easily managed with hyperventilation and administration of 1 g/kg of 20% mannitol. Following this unexpected surge in ICP after administration of morphine, the fentanyl infusion she had been receiving since hospital day 1 was discontinued with an ensuing decline in ICP over the next 24 h which reached single digits for the first time since monitoring was started. No new interventions were introduced during this period. Parallel with the normalization of ICP was a resolution of her persistent sinus tachycardia and intermittent arterial hypertension. Permitting transient increases of ICPs up to 30 mmHg after stimulation, we were able to rapidly resume normothermia (36.5°C), discontinue neuromuscular paralysis, and transition from propofol to a low dose of midazolam without the need for rescue doses of hyperosmolar therapy . Before discontinuation of the ICP monitoring, her ICPs had steadily settled below 15 mmHg.", + "fulltext_subclaims": [ + "The patient was a 19-year-old woman.", + "She was the restrained driver in a roll-over accident at highway speed.", + "Her Glasgow coma scale was 4.", + "She exhibited extensor posturing.", + "She was sedated, paralyzed, intubated, and transported to the hospital as a level 1 trauma.", + "Her medical history was unremarkable.", + "CT imaging of the head revealed multiple punctate hemorrhagic lesions.", + "CT imaging showed early effacement of the gray-white junction.", + "CT imaging showed diffuse traumatic subarachnoid hemorrhage.", + "An intraparenchymal ICP monitor was placed.", + "Initial ICP readings were 23–25 mmHg.", + "Supportive care included midline placement of the head.", + "Supportive care included elevation of the head to 30°.", + "Sedation was provided with propofol.", + "Analgesia was provided with fentanyl.", + "She required bolus doses of 20% mannitol for ICP surges with physical stimulation.", + "On hospital day 3, she developed refractory intracranial hypertension.", + "On hospital day 3, she developed fever.", + "The fever persisted through hospital day 12.", + "She was very sensitive to physical stimulation.", + "Changes in position resulted in ICP spikes.", + "Tracheal suctioning resulted in ICP spikes.", + "Osmotic therapy included alternating boluses of 20% mannitol and 23% saline.", + "Maintenance fluids were changed to 3% saline solution.", + "Mild hypernatremia was induced.", + "Mild hypothermia (35°C) was induced using the Arctic Sun device.", + "Pharmacological neuromuscular paralysis was used to control the shivering response.", + "Several attempts to reduce the degree of metabolic suppression failed.", + "She consistently required a temperature under 35°C.", + "She consistently required a dose of Propofol greater than 40 mcg/kg/min.", + "A repeat CT scan on hospital day 11 did not show significant cerebral edema.", + "She was consistently tachycardic.", + "She had intermittent periods of hypertension.", + "This raised the possibility of sympathetic hyperactivity.", + "She was started on propranolol.", + "On hospital day 12, a bolus of 4 mg of morphine was administered.", + "Following morphine administration, ICP rose steadily from 30 mmHg to 55 mmHg over 3 min.", + "The ICP surge was managed with hyperventilation.", + "The ICP surge was managed with 1 g/kg of 20% mannitol.", + "Following the ICP surge, the fentanyl infusion was discontinued.", + "Following discontinuation of fentanyl, ICP declined over the next 24 h.", + "ICP reached single digits for the first time since monitoring was started.", + "No new interventions were introduced during this period.", + "Her persistent sinus tachycardia resolved.", + "Her intermittent arterial hypertension resolved.", + "Permitting transient increases of ICPs up to 30 mmHg after stimulation, normothermia was rapidly resumed.", + "Neuromuscular paralysis was discontinued.", + "Propofol was transitioned to a low dose of midazolam.", + "No rescue doses of hyperosmolar therapy were needed.", + "Before discontinuation of the ICP monitoring, ICPs had steadily settled below 15 mmHg." + ], + "summary": "A patient with refractory intracranial hypertension after closed head injury was managed with standard medical therapy with only transient decreases in the ICP. Only after discontinuation of opiates did the ICP become manageable without metabolic suppression and rescue osmotic therapy, implicating opiates as the etiology of refractory intracranial hypertension in this patient.", + "summary_subclaims": [ + "A patient with refractory intracranial hypertension after closed head injury was managed with standard medical therapy.", + "Standard medical therapy resulted in only transient decreases in the ICP.", + "Only after discontinuation of opiates did the ICP become manageable.", + "The ICP became manageable without metabolic suppression.", + "The ICP became manageable without rescue osmotic therapy.", + "Opiates are implicated as the etiology of refractory intracranial hypertension in this patient." + ] + }, + { + "id": "multiclinsum_test_456_en.txt", + "fulltext": "A 31-year old Caucasian, Turkish male patient was admitted to our emergency department with the complaints of nausea and vomiting occurring few hours. It was learned that these complaints were repeating after meals for a week, episodically. On admission he looked severely ill and dehydrated. Abdominal examination revealed distension and clanging intestinal sounds. Laboratory investigation showed that leukocytosis (13400/mm3), sodium: 134 mmol/L, potassium: 3.2 mmol/L. Plain films of abdomen disclosed multiple intestinal air-fluid levels. Contrast enhanced computed tomography showed intestinal obstruction without an obvious cause.\nUpon appropriate fluid resuscitation the patient underwent diagnostic laparatomy. In this process, it was seen that an approximately 10-cm of invaginated mid-jejunal segment . The pathologic segment was resected and end-to-end anastomosis was performed. The patient was discharged in a well condition 6 days after the surgery.\nMacroscopic examination of surgical specimen demonstrated a hard polypoid tumor approximately 3-cm in diameter, originating from submucosa and making ulceration by extending mucosa .\nHistopathologic examination showed proliferated vessel formations in fibrotic stroma, dense inflammatory mononuclear cell infiltration and polypoid tissue with patchy necrotic areas. The connective tissue of polyp was rich in fibroblasts and eosinophils. Vessel congestions were observed at submucosa and mucosa as well. With these findings polypoid lesion was classified as inflammatory fibroid polyp (IFP) .", + "fulltext_subclaims": [ + "The patient is a 31-year-old Caucasian, Turkish male.", + "The patient was admitted with complaints of nausea and vomiting occurring few hours.", + "The complaints were repeating after meals for a week, episodically.", + "On admission, the patient looked severely ill and dehydrated.", + "Abdominal examination revealed distension and clanging intestinal sounds.", + "Laboratory investigation showed leukocytosis (13400/mm3).", + "Plain films of the abdomen disclosed multiple intestinal air-fluid levels.", + "Contrast enhanced computed tomography showed intestinal obstruction without an obvious cause.", + "The patient underwent diagnostic laparotomy.", + "An approximately 10-cm invaginated mid-jejunal segment was seen.", + "The pathologic segment was resected and end-to-end anastomosis was performed.", + "The patient was discharged 6 days after the surgery.", + "Macroscopic examination of the surgical specimen demonstrated a hard polypoid tumor approximately 3-cm in diameter.", + "The tumor originated from submucosa and made ulceration by extending mucosa.", + "Histopathologic examination showed proliferated vessel formations in fibrotic stroma.", + "Dense inflammatory mononuclear cell infiltration was observed.", + "Polypoid tissue with patchy necrotic areas was observed.", + "The connective tissue of the polyp was rich in fibroblasts and eosinophils.", + "Vessel congestions were observed at submucosa and mucosa.", + "The polypoid lesion was classified as inflammatory fibroid polyp (IFP)." + ], + "summary": "A 31-year old male patient was admitted to our emergency department few hours after complaints of nausea and vomiting. Abdominal examination revealed distension and clanging intestinal sounds. Computed tomography showed intestinal obstruction without an obvious cause. The patient underwent diagnostic laparotomy. In this process, approximately 10 cm of invaginated mid-jejunal segment was seen. The pathologic segment was resected and end-to-end anastomosis was performed. The patient was discharged without any complication.", + "summary_subclaims": [ + "The patient was a 31-year old male.", + "The patient was admitted to the emergency department.", + "The admission occurred few hours after complaints of nausea and vomiting.", + "Abdominal examination revealed distension.", + "Computed tomography showed intestinal obstruction.", + "The computed tomography showed intestinal obstruction without an obvious cause.", + "The patient underwent diagnostic laparotomy.", + "Approximately 10 cm of invaginated mid-jejunal segment was seen.", + "The pathologic segment was resected.", + "End-to-end anastomosis was performed.", + "The patient was discharged without any complication." + ] + }, + { + "id": "multiclinsum_test_591_en.txt", + "fulltext": "A 30-year-old man of Asian origin, presented to the surgery outpatient department (OPD) with non-radiating pain in the right hypochondrium and epigastrium associated with vomiting, intermittent fever with chills and rigors for 10 days. The onset was gradual with increasing weakness and deterioration of his general health. The patient was undergoing follow-up for a liver abscess (right lobe) which was diagnosed previously as an amoebic liver abscess (ALA) based on a positive amoebic serology report from a private laboratory. He was treated conservatively for this and discharged 3 months before this present episode. There was no previous history of tuberculosis (TB) or contact with any patient with TB. At the time of admission, the patient was febrile, dehydrated and looked very ill and anemic with a pulse rate of 92/minute, blood pressure 106/70 mmHg and respiratory rate of 16/minute. There was no icterus and no lymphadenopathy. Abdominal examination revealed tenderness and guarding over the intercostal spaces overlying the liver. The liver span was 16 cm. There was no splenomegaly, ascites or any other palpable mass in his abdomen. Respiratory and cardiovascular system (CVS) examination revealed no abnormality.\nChest X-ray showed no lesion suggestive of TB but revealed a right-sided subdiaphragmatic pathology as the right hemi-diaphragm was raised and the costophrenic angle was blunted. An ultrasonogram (USG) of the abdomen on the same day revealed a 5.6 × 6.8 × 8.8 cm ill-defined, heterogeneous hypo-echoic lesion reaching up to the liver surface with cystic areas in the right lobe of the liver suggestive of an abscess . His liver was enlarged with a span of 16.6 cm with no other focal lesion. No perihepatic or pleural effusion was seen. All other abdominal viscera appeared normal with no free fluid.\nRoutine hematology investigations showed hemoglobin 9.3 gm/dl; total leukocyte count (TLC) 22,600/mm3; differential leukocyte count (DLC): polymorphs 76, lymphocytes 20, monocytes 2, eosinophils 2; platelet count 3.76 lac; erythrocyte sedimentation rate (ESR) 52 mm at the end of the first hour; blood urea 28 mg%; prothrombin time of 15 seconds with a control of 10.1 seconds; total bilirubin 1 mg%; serum alkaline phosphatase 7 IU; serum glutamic oxaloacetic acid transaminase (SGOT) 29 IU; serum glutamic pyruvate transaminase (SGPT) 39 IU; serum protein 6.6 g/dl and serum albumin 4.0 g/dl.\nPigtail catheterization was carried out under local anesthetic (LA), which drained 150 ml of cream-colored pus. The pus was sent for Ziehl-Neelsen (ZN) staining, acid-fast bacilli (AFB) culture using a BACTEC TB 460 instrument, polymerase chain reaction (PCR) assay for Mycobacterium tuberculosis and other routine microbiological investigations (wet mount, Gram stain, pus culture for bacteria and fungi). ZN staining showed AFB and BACTEC culture confirmed the same by isolating M. tuberculosis (by para-nitro-alpha-acetylamino-beta-hydroxy-propiophenone (NAP) test). Antibiotic sensitivity was performed with the BACTEC TB 460 instrument and the isolate was sensitive to isoniazid, streptomycin, rifampicin and ethambutol. PCR assay of the aspirate was also positive for M. tuberculosis DNA. The lysozyme proteinase K extraction method was used to extract the DNA. The target for amplification was a MPB 64 gene which has a 240 bp sized amplicon. The primers used in the PCR assay were as follows:\nPrimer 1: 5'-TCC GCT GCC AGT CGT CTTCC-3'\nPrimer 2: 5'-GTC CTC GCG AGT CTA GGCCA-3'\nOther routine microbiological investigations did not reveal any significant findings. Wet mount showed no trophozoites of Entamoeba histolytica or any fungal element. A routine bacteriological culture was sterile. Three consecutive early morning sputum samples were also screened for AFB and were negative. The patient was non-reactive in HIV serology. He was started on systemic antitubercular treatment (ATT) on receipt of the results from the laboratory, and this included isoniazid (300 mg once daily), rifampicin (450 mg once daily), pyrazinamide (1200 mg once daily), ethambutol (750 mg once daily) and pyridoxine (20 mg once daily). His fever subsided, and his appetite and general condition improved. He was discharged with stable vitals and asked to come for follow-up checkups after 6 weeks. At the first follow-up visit, the patient was asymptomatic, his liver size had decreased (size 3.1 × 3.8 × 5.1 cm) and a repeat USG abdomen revealed regression of the abscess.", + "fulltext_subclaims": [ + "A 30-year-old man of Asian origin presented with non-radiating pain in the right hypochondrium and epigastrium.", + "The pain was associated with vomiting, intermittent fever with chills and rigors for 10 days.", + "The patient had a previous diagnosis of a right lobe liver abscess.", + "The previous liver abscess was diagnosed as an amoebic liver abscess.", + "The previous diagnosis was based on a positive amoebic serology report from a private laboratory.", + "The patient was treated conservatively for the previous liver abscess.", + "The patient was discharged 3 months before this present episode.", + "There was no previous history of tuberculosis.", + "There was no contact with any patient with tuberculosis.", + "At the time of admission, the patient was febrile.", + "At the time of admission, the patient was dehydrated.", + "Abdominal examination revealed tenderness and guarding over the intercostal spaces overlying the liver.", + "The liver span was 16 cm.", + "Chest X-ray showed a right-sided subdiaphragmatic pathology.", + "An ultrasonogram of the abdomen revealed a 5.6 × 6.8 × 8.8 cm ill-defined, heterogeneous hypo-echoic lesion in the right lobe of the liver.", + "The lesion was suggestive of an abscess.", + "Pigtail catheterization drained 150 ml of cream-colored pus.", + "ZN staining showed acid-fast bacilli.", + "BACTEC culture confirmed the presence of Mycobacterium tuberculosis.", + "The isolate was sensitive to isoniazid, streptomycin, rifampicin, and ethambutol.", + "PCR assay of the aspirate was positive for Mycobacterium tuberculosis DNA.", + "The patient was started on systemic antitubercular treatment.", + "The treatment included isoniazid, rifampicin, pyrazinamide, ethambutol, and pyridoxine.", + "The patient's fever subsided.", + "The patient's appetite and general condition improved.", + "The patient was discharged with stable vitals.", + "At the first follow-up visit, the patient was asymptomatic.", + "A repeat USG abdomen revealed regression of the abscess." + ], + "summary": "A 30-year-old man, of Asian origin, developed a hepatic tubercular abscess which was not associated with any pulmonary or gastrointestinal tract foci of tuberculosis. An ultrasonogram of the abdomen showed an abscess in the right lobe of his liver which was initially diagnosed as an amoebic liver abscess. Subsequently, the pus from the lesion yielded Mycobacterium tuberculosis using the BACTEC TB 460 instrument and Mycobacterium tuberculosis deoxyribonucleic acid by polymerase chain reaction. The patient was started on systemic antitubercular therapy to which he responded favorably.", + "summary_subclaims": [ + "The patient is a 30-year-old man.", + "The patient is of Asian origin.", + "The patient developed a hepatic tubercular abscess.", + "The hepatic tubercular abscess was not associated with any pulmonary or gastrointestinal tract foci of tuberculosis.", + "An ultrasonogram of the abdomen showed an abscess in the right lobe of his liver.", + "The abscess was initially diagnosed as an amoebic liver abscess.", + "The pus from the lesion yielded Mycobacterium tuberculosis using the BACTEC TB 460 instrument.", + "The pus from the lesion yielded Mycobacterium tuberculosis deoxyribonucleic acid by polymerase chain reaction.", + "The patient was started on systemic antitubercular therapy.", + "The patient responded favorably to the systemic antitubercular therapy." + ] + }, + { + "id": "multiclinsum_test_654_en.txt", + "fulltext": "A 61-year-old woman with a past medical history of type II diabetes, breast cancer, and major depression presented to the emergency department after an intentional overdose with fluoxetine (139 tablets of 20 mg), risperidone (6 tablets of 1 mg), bromazepam (90 tablets of 3 mg), zolpidem (40 tablets of 10 mg), naproxen (20 tablets of 500 mg), and clemastine (5 tablets of 1 mg). Quantities were determined by counting the remaining pills in the blister packaging. Upon arrival, the patient was somnolent but able to open her eyes on request (E3M6V5). Vital signs showed a blood pressure of 146/57 mmHg, a regular heart rate of 55/min with strong peripheral pulsations, a respiratory rate of 16/min, oxygen saturation levels varying between 95 and 100% at room air, and a body temperature of 36.2 °C. Her husband suggested that the pills must have been ingested 3 to 8 h prior to hospital admission. Electrocardiography (ECG) showed a sinus rhythm of 61 beats per minute with a prolonged corrected QT interval (QTc) of 503 ms as shown in Fig. . During admission, all ECGs were performed using a GE MAC 5500 HD electrocardiograph. The tangent method was used in order to define the end of the T-wave in the lead with the longest QT interval. All measured QTc intervals were corrected for cardiac frequency using Bazett’s formula .\nInitial laboratory findings showed a microcytic anemia (Hb 5.4 mmol/l, MCV 77 fl) with low serum ferritin (6 μg/l), along with a mild leukocytosis of 11.2/nl. Serum electrolytes, as well as liver and kidney function, were normal (Na+ 135 mmol/l, K+ 4.3 mmol/l, creatinine 89 μmol/l, corrected calcium 2.37 mmol/l, PO43− 1.41 mmol/l, magnesium 0.83 mmol/l). Arterial blood gas analysis showed a base excess of − 4.9 mmol/l (pH 7.37, pCO2 4.6 kPa, pO2 12.1 kPa, HCO3− 20 mmol/l). A chest X-ray displayed no aspiration pneumonia nor other cardiopulmonary anomalies. The patient was admitted to the ICU for observation, where she received intravenous fluids along with 40 mg of pantoprazole for the prevention of peptic ulcer disease due to the substantial ingestion of naproxen. This was administered only once due to the risk of further QTc interval prolongation. Initially, our patient remained hemodynamically stable and showed improved neurological function. Twenty-two hours after hospital admission, a second ECG showed normalization of the QTc interval to 458 ms, suggesting peak serum levels of the ingested drugs had passed. After psychiatric evaluation had taken place, our patient had fallen to the floor in search of the restroom. On examination, both her muscle strength and coordination were slightly disturbed. Due to the overall severity of the intoxication and the persistence of neurological symptoms, it was decided to observe the patient for one more night at the ICU. Flumazenil was not administered since the patient was fully conscious and already in a monitored environment and due to the risk of adverse effects, especially with chronic benzodiazepine use .\nThat night, 36 h after admission, our patient developed recurrent short episodes of Torsades de Pointes (TdP) with intermittent loss of cardiac output, as shown in Fig. . Two grams of magnesium sulphate was administered intravenously, after which sinus rhythm was restored. Four hours later, she had complete loss of circulation, after which cardiopulmonary resuscitation was initiated according to protocol. A 150-J biphasic shock was delivered using an automated external defibrillator (Zoll R-Series ALS). ECG findings consistent with TdP were again observed. Spontaneous circulation was restored after intravenous administration of magnesium sulphate. Our patient was awake and immediately able to maintain a patent airway following the incident. Serum levels of fluoxetine and risperidone and their metabolites were measured in retrospect, as shown in Table and Fig. , . Laboratory findings at the time of the incident showed a mild hypocalcaemia of 2.10 mmol/l with a hypermagnesaemia of 1.72 mmol/l/, most likely caused due to the prior administration of magnesium sulphate. No other electrolyte abnormalities were identified (Na+ 137 mmol/l, K+ 3.8 mmol/l, PO43− 1.24 mmol/l). Subsequent ECGs showed progressive prolongation of the QTc interval up to 565 ms, as shown in Fig. . The patient remained hemodynamically stable for the remainder of the night on continuous infusion of magnesium sulphate (1 g/h). The following day, echocardiography was performed in order to exclude structural cardiac defects, which showed normal heart dimensions as well as a normal left and right ventricular function.", + "fulltext_subclaims": [ + "The patient is a 61-year-old woman.", + "The patient has a past medical history of type II diabetes.", + "The patient has a past medical history of breast cancer.", + "The patient has a past medical history of major depression.", + "The patient presented after an intentional overdose.", + "The overdose included 139 tablets of 20 mg fluoxetine.", + "The overdose included 6 tablets of 1 mg risperidone.", + "The overdose included 90 tablets of 3 mg bromazepam.", + "The overdose included 40 tablets of 10 mg zolpidem.", + "The overdose included 20 tablets of 500 mg naproxen.", + "The overdose included 5 tablets of 1 mg clemastine.", + "The quantities were determined by counting the remaining pills in the blister packaging.", + "Upon arrival, the patient was somnolent but able to open her eyes on request (E3M6V5).", + "Vital signs showed a blood pressure of 146/57 mmHg.", + "Vital signs showed a regular heart rate of 55/min with strong peripheral pulsations.", + "Vital signs showed a respiratory rate of 16/min.", + "Vital signs showed oxygen saturation levels varying between 95 and 100% at room air.", + "Vital signs showed a body temperature of 36.2 °C.", + "The husband suggested that the pills must have been ingested 3 to 8 h prior to hospital admission.", + "Electrocardiography (ECG) showed a prolonged corrected QT interval (QTc) of 503 ms.", + "All ECGs were performed using a GE MAC 5500 HD electrocardiograph.", + "The tangent method was used to define the end of the T-wave in the lead with the longest QT interval.", + "All measured QTc intervals were corrected for cardiac frequency using Bazett’s formula.", + "Initial laboratory findings showed a microcytic anemia (Hb 5.4 mmol/l, MCV 77 fl).", + "Initial laboratory findings showed low serum ferritin (6 μg/l).", + "Initial laboratory findings showed a mild leukocytosis of 11.2/nl.", + "Serum electrolytes, as well as liver and kidney function, were normal.", + "Arterial blood gas analysis showed a base excess of −4.9 mmol/l.", + "A chest X-ray displayed no aspiration pneumonia.", + "The patient was admitted to the ICU for observation.", + "The patient received intravenous fluids.", + "The patient received 40 mg of pantoprazole.", + "Pantoprazole was administered only once due to the risk of further QTc interval prolongation.", + "Twenty-two hours after hospital admission, a second ECG showed normalization of the QTc interval to 458 ms.", + "After psychiatric evaluation, the patient had fallen to the floor in search of the restroom.", + "On examination, both her muscle strength and coordination were slightly disturbed.", + "It was decided to observe the patient for one more night at the ICU.", + "Flumazenil was not administered.", + "The patient was fully conscious.", + "The patient was already in a monitored environment.", + "Flumazenil was not administered due to the risk of adverse effects, especially with chronic benzodiazepine use.", + "36 h after admission, the patient developed recurrent short episodes of Torsades de Pointes (TdP) with intermittent loss of cardiac output.", + "Two grams of magnesium sulphate was administered intravenously.", + "After magnesium sulphate, sinus rhythm was restored.", + "Four hours later, she had complete loss of circulation.", + "Cardiopulmonary resuscitation was initiated according to protocol.", + "A 150-J biphasic shock was delivered using an automated external defibrillator (Zoll R-Series ALS).", + "ECG findings consistent with TdP were again observed.", + "Spontaneous circulation was restored after intravenous administration of magnesium sulphate.", + "The patient was awake and immediately able to maintain a patent airway following the incident.", + "Laboratory findings at the time of the incident showed a mild hypocalcaemia of 2.10 mmol/l.", + "Laboratory findings at the time of the incident showed a hypermagnesaemia of 1.72 mmol/l.", + "No other electrolyte abnormalities were identified.", + "Subsequent ECGs showed progressive prolongation of the QTc interval up to 565 ms.", + "The patient remained hemodynamically stable for the remainder of the night on continuous infusion of magnesium sulphate (1 g/h).", + "Echocardiography was performed the following day.", + "Echocardiography showed normal heart dimensions.", + "Echocardiography showed a normal left and right ventricular function." + ], + "summary": "A 61-year-old woman presented to the emergency department after an intentional multiple drug overdose. Upon examination, she was somnolent with stable respiration and hemodynamics. Electrocardiography showed a prolonged QTc interval of 503 ms. The patient was admitted to the ICU for cardiopulmonary monitoring. During admission, the patient remained stable and showed improved neurologic function over time. After 22 h, a second ECG showed normalization of the QTc interval to 458 ms. However, 36 to 40 h after admission, our patient developed recurrent episodes of Torsades de Pointes (TdP) with loss of cardiac output, leading to cardiopulmonary resuscitation. Spontaneous circulation was restored after intravenous administration of magnesium sulphate. Retrospective serum analysis revealed fluoxetine concentrations of 2700 mcg/l.", + "summary_subclaims": [ + "The patient was a 61-year-old woman.", + "She presented to the emergency department after an intentional multiple drug overdose.", + "Upon examination, she was somnolent.", + "Electrocardiography showed a prolonged QTc interval of 503 ms.", + "The patient was admitted to the ICU for cardiopulmonary monitoring.", + "During admission, the patient remained stable.", + "After 22 h, a second ECG showed normalization of the QTc interval to 458 ms.", + "36 to 40 h after admission, the patient developed recurrent episodes of Torsades de Pointes.", + "The patient had loss of cardiac output.", + "Spontaneous circulation was restored after intravenous administration of magnesium sulphate.", + "Retrospective serum analysis revealed fluoxetine concentrations of 2700 mcg/l." + ] + }, + { + "id": "multiclinsum_test_932_en.txt", + "fulltext": "A female infant was born at 27 weeks of gestation to a 33-year-old, Gravida 8, Para 5 mother. The pregnancy was complicated by subchorionic hemorrhage at 11 weeks, rupture of amniotic membranes at 24 weeks gestation, and intrauterine growth restriction with absent end-diastolic flow of the umbilical artery. Doppler scans and a poor biophysical profile (2/8) at 27 weeks highlighted the need for an urgent cesarean section.\nThe patient received a complete two-dose course of betamethasone at 24 weeks and a single rescue dose before the C-section at 27 weeks. The birth weight was 680 g (13th percentile), and the head circumference was 22 cm (6th percentile). The infant received delayed cord clamping for 1 min, and her 5-min Apgar score was 8. Noninvasive intermittent positive pressure (NIPPV) was initiated in the delivery room, which was continued on admission to the NICU.\nA chest X-ray showed radiographic features of RDS . There was an increase in the oxygen and ventilatory requirements. The infant met the institutional criteria for surfactant delivery via LISA. In our institute, the surfactant is administered via the “Hobart method”, which utilizes a semirigid 16-G catheter that is placed into the trachea without the use of Magill forceps. Bovine lipid extract surfactant (BLES®, 5 ml/kg) was successfully instilled.\nThe catheter was prepared by removing the introducer needle and marking the desired estimated depth. The catheter tip was slightly curved to mimic the natural airway anatomy to facilitate the insertion past the vocal cords. The infant was premedicated with atropine and fentanyl.\nThe procedure was performed by a neonatal physician trainee who was certified to perform LISA. The vocal cords could easily be visualized using a laryngoscope. Despite easy visualization, an attempt to insert the catheter between the vocal cords to the desired depth failed due to unexpected resistance. Given that the angiocath tip was passed beyond the vocal cords, a decision was made to start the instillation of surfactant. However, resistance was encountered during instillation, which prevented the administration of surfactant. At this point, a second visualization with the laryngoscope was conducted that confirmed that the catheter was through the vocal cords. The angiocath was then withdrawn by 0.5 cm.\nA second attempt to deliver surfactant was performed, and this time, it was successfully instilled without any resistance. Subtle subcutaneous neck swelling was noted after the procedure, vital signs were normal, and no bleeding or clinical deterioration was observed. The orogastric tube was aspirated, and no surfactant was retrieved, thereby confirming that there was no inadvertent intragastric delivery of surfactant. The oxygen could be weaned down from 30 to 21% by 45 min after the procedure, and the ventilatory parameters were weaned.\nThree hours after the procedure, the infant became hypotensive. A pneumothorax was suspected, so chest X-ray was ordered and revealed a pneumomediastinum . The air leak was localized to the anterior mediastinum, with a linear radiolucency showing a tract to the anterior aspect of the trachea close to the level of the vocal cords, suggesting a high tracheal perforation. Air tracking up to the soft tissue in the neck region was noted, suggesting subcutaneous emphysema.\nThe infant required prompt management of hypotension, which was addressed with a fluid bolus of normal saline, and needed initiation of dopamine that was ultimately weaned off 8 h later. The pneumomediastinum was conservatively managed with close monitoring of the clinical condition and switching from NIPPV to nasal continuous positive airway pressure (nCPAP) and decreasing positive end-expiratory pressure (PEEP).\nThe infant remained stable from a respiratory perspective on a low level of noninvasive support. Follow-up chest X-ray revealed a gradual resolution of the pneumomediastinum, and a complete resolution of the radiographic findings was noted by day 10 of life. There was no need for a further dose of surfactant or intubation for mechanical ventilation.\nThe newborn was transitioned from nCPAP to a high-flow nasal cannula at 32 weeks. Cranial ultrasound performed on day 3 showed a grade 2 germinal matrix hemorrhage on the right side and a periventricular hemorrhage on the left side.\nSubsequent cranial ultrasound examinations demonstrated the evolution of periventricular hemorrhage into cystic lesions. The infant had a brain MRI at 32 weeks that showed similar findings. The newborn also had an episode of late-onset sepsis at 20 days of life that was successfully treated with antibiotics. Enteral nutrition was gradually established. The infant was completely off respiratory support by day 50 of life at the corrected gestational age of 34 plus 1 day and therefore did not develop bronchopulmonary dysplasia. The infant was discharged home at 40 weeks’ gestation.", + "fulltext_subclaims": [ + "The patient was born at 27 weeks of gestation.", + "The mother was 33 years old.", + "The mother was Gravida 8, Para 5.", + "The pregnancy was complicated by subchorionic hemorrhage at 11 weeks.", + "The pregnancy was complicated by rupture of amniotic membranes at 24 weeks gestation.", + "The pregnancy was complicated by intrauterine growth restriction with absent end-diastolic flow of the umbilical artery.", + "Doppler scans and a poor biophysical profile (2/8) at 27 weeks highlighted the need for an urgent cesarean section.", + "The patient received a complete two-dose course of betamethasone at 24 weeks.", + "The patient received a single rescue dose of betamethasone before the C-section at 27 weeks.", + "The birth weight was 680 g.", + "The head circumference was 22 cm.", + "The infant received delayed cord clamping for 1 min.", + "The 5-min Apgar score was 8.", + "Noninvasive intermittent positive pressure (NIPPV) was initiated in the delivery room.", + "NIPPV was continued on admission to the NICU.", + "A chest X-ray showed radiographic features of RDS.", + "There was an increase in the oxygen and ventilatory requirements.", + "The infant met the institutional criteria for surfactant delivery via LISA.", + "The surfactant was administered via the “Hobart method”.", + "The “Hobart method” utilizes a semirigid 16-G catheter.", + "The catheter was placed into the trachea without the use of Magill forceps.", + "Bovine lipid extract surfactant (BLES®, 5 ml/kg) was successfully instilled.", + "The catheter was prepared by removing the introducer needle and marking the desired estimated depth.", + "The catheter tip was slightly curved to mimic the natural airway anatomy.", + "The infant was premedicated with atropine and fentanyl.", + "The procedure was performed by a neonatal physician trainee who was certified to perform LISA.", + "The vocal cords could easily be visualized using a laryngoscope.", + "An attempt to insert the catheter between the vocal cords to the desired depth failed due to unexpected resistance.", + "A decision was made to start the instillation of surfactant.", + "Resistance was encountered during instillation, which prevented the administration of surfactant.", + "A second visualization with the laryngoscope was conducted.", + "The second visualization confirmed that the catheter was through the vocal cords.", + "The angiocath was then withdrawn by 0.5 cm.", + "A second attempt to deliver surfactant was performed.", + "The surfactant was successfully instilled without any resistance.", + "Subtle subcutaneous neck swelling was noted after the procedure.", + "No bleeding or clinical deterioration was observed.", + "The orogastric tube was aspirated.", + "No surfactant was retrieved, thereby confirming that there was no inadvertent intragastric delivery of surfactant.", + "The oxygen could be weaned down from 30 to 21% by 45 min after the procedure.", + "The ventilatory parameters were weaned.", + "Three hours after the procedure, the infant became hypotensive.", + "A pneumothorax was suspected.", + "A chest X-ray was ordered.", + "The chest X-ray revealed a pneumomediastinum.", + "The air leak was localized to the anterior mediastinum.", + "A linear radiolucency showed a tract to the anterior aspect of the trachea close to the level of the vocal cords.", + "The radiolucency suggested a high tracheal perforation.", + "Air tracking up to the soft tissue in the neck region was noted.", + "The air tracking suggested subcutaneous emphysema.", + "The infant required prompt management of hypotension.", + "The hypotension was addressed with a fluid bolus of normal saline.", + "The infant needed initiation of dopamine.", + "Dopamine was ultimately weaned off 8 h later.", + "The pneumomediastinum was conservatively managed.", + "The pneumomediastinum was managed with close monitoring of the clinical condition.", + "The pneumomediastinum was managed by switching from NIPPV to nasal continuous positive airway pressure (nCPAP).", + "The pneumomediastinum was managed by decreasing positive end-expiratory pressure (PEEP).", + "The infant remained stable from a respiratory perspective on a low level of noninvasive support.", + "Follow-up chest X-ray revealed a gradual resolution of the pneumomediastinum.", + "A complete resolution of the radiographic findings was noted by day 10 of life.", + "There was no need for a further dose of surfactant.", + "There was no need for intubation for mechanical ventilation.", + "The newborn was transitioned from nCPAP to a high-flow nasal cannula at 32 weeks.", + "Cranial ultrasound performed on day 3 showed a grade 2 germinal matrix hemorrhage on the right side.", + "Cranial ultrasound performed on day 3 showed a periventricular hemorrhage on the left side.", + "Subsequent cranial ultrasound examinations demonstrated the evolution of periventricular hemorrhage into cystic lesions.", + "The infant had a brain MRI at 32 weeks that showed similar findings.", + "The infant had an episode of late-onset sepsis at 20 days of life.", + "The late-onset sepsis was successfully treated with antibiotics.", + "Enteral nutrition was gradually established.", + "The infant was completely off respiratory support by day 50 of life.", + "The infant was completely off respiratory support at the corrected gestational age of 34 plus 1 day.", + "The infant did not develop bronchopulmonary dysplasia.", + "The infant was discharged home at 40 weeks’ gestation." + ], + "summary": "A preterm newborn born at 27 weeks of gestation presented with respiratory distress syndrome requiring surfactant replacement. LISA using the Hobart method was completed. There was a report of procedural difficulty related to increased resistance to insertion of the 16G angiocath. The newborn was subsequently noted to have subcutaneous emphysema over the anterior aspect of the neck and substantial pneumomediastinum on radiological assessment. Associated complications included hypotension requiring inotropic support. The newborn was successfully managed conservatively, with complete resolution of the air leak.", + "summary_subclaims": [ + "The newborn was born at 27 weeks of gestation.", + "The newborn presented with respiratory distress syndrome.", + "The newborn required surfactant replacement.", + "LISA using the Hobart method was completed.", + "There was a report of procedural difficulty related to increased resistance to insertion of the 16G angiocath.", + "The newborn was noted to have subcutaneous emphysema over the anterior aspect of the neck.", + "The newborn had substantial pneumomediastinum on radiological assessment.", + "The newborn had hypotension requiring inotropic support.", + "The newborn was successfully managed conservatively.", + "The air leak completely resolved." + ] + }, + { + "id": "multiclinsum_test_2062_en.txt", + "fulltext": "The case was a 25-year-old MG3L1ab2 woman with a history of infertility, complaining from irregular uterine bleeding and she was diagnosed with a pelvic mass in MRI. She got married 7 years ago.\nAll of her pregnancies were by induction and ovulation and the first and second pregnancies were aborted spontaneously between 6 and 8 weeks. The third pregnancy, 3 years ago, was terminated by cesarean section and resulted in the birth of a healthy baby.\nThe patient who had menorrhagia for the last 6 months was examined for irregular uterine bleeding. She also complained about occasional pains under the abdomen and in the right upper quadrant abdomen. In MRI, the retroperitoneal uterus and endometrial thickness was 5 mm, and a mass with an abnormal heterogeneous signal and heterogenic enhancement of about 95×80 mm in the anterolateral and right border of the hip with the extension to the hypogastric region was reported suggesting tumoral lesions in the right ovary or endometrium .\nAccording to the report of the ovarian mass in MRI, the patient became a candidate for laparoscopy.\nThe laparoscopic surgery was planned in the operating room of Mehr Hospital in Mashhad on January 10, 2018. Initially, to enter the abdominal cavity, there was no possibility of passing the veress needle through abdominal wall from the umbilicus and the Palmer’s point, so the decision was made to enter the abdominal cavity through open laparoscopy. After creating a 2 cm incision in the umbilicus, and touching with finger, a solid and abnormal texture in this place was observed. Therefore, the decision was made to continue the operation by laparotomy.\nThe abdomen was opened with a midline incision and a solid mass was in the midline of the abdominal wall adhering to the rectus muscles and the fascia with 12 cm in size. First, the mass was dissected from the rectus muscles and the peritoneum below it. After complete dissection, it was observed that the mass was connected to the abdominal wall with a relatively thick bundle (2 cm) in the suprapubic region .\nThe mass was similar to uterine fibroids in shape and consistency. After complete removal of the mass, in the examination of the abdominal wall, the visceral peritoneum was completely healthy. The visceral peritoneum was opened to check the abdominal cavity. No specific pathological findings were observed in the examination of the abdomen and pelvis. The uterus and adnexa were completely healthy and there was no evidence of adhesion, mass or ovarian cyst or uterine fibroids. So, the surgery was terminated.\nPathology report of the abdominal wall mass was leiomyoma.", + "fulltext_subclaims": [ + "The patient was a 25-year-old MG3L1ab2 woman.", + "She had a history of infertility.", + "She complained of irregular uterine bleeding.", + "She was diagnosed with a pelvic mass in MRI.", + "She got married 7 years ago.", + "All of her pregnancies were by induction and ovulation.", + "The first and second pregnancies were aborted spontaneously between 6 and 8 weeks.", + "The third pregnancy was terminated by cesarean section.", + "The third pregnancy resulted in the birth of a healthy baby.", + "She had menorrhagia for the last 6 months.", + "She complained about occasional pains under the abdomen.", + "She complained about occasional pains in the right upper quadrant abdomen.", + "In MRI, the retroperitoneal uterus was reported.", + "In MRI, the endometrial thickness was 5 mm.", + "A mass with an abnormal heterogeneous signal was reported.", + "The mass had heterogenic enhancement.", + "The mass was about 95×80 mm in size.", + "The mass was located in the anterolateral and right border of the hip.", + "The mass extended to the hypogastric region.", + "The mass was reported to suggest tumoral lesions in the right ovary or endometrium.", + "The patient became a candidate for laparoscopy.", + "The laparoscopic surgery was planned in the operating room of Mehr Hospital in Mashhad.", + "The laparoscopic surgery was planned for January 10, 2018.", + "There was no possibility of passing the veress needle through the umbilicus.", + "There was no possibility of passing the veress needle through the Palmer’s point.", + "The decision was made to enter the abdominal cavity through open laparoscopy.", + "A 2 cm incision was created in the umbilicus.", + "A solid and abnormal texture was observed in the umbilicus.", + "The decision was made to continue the operation by laparotomy.", + "The abdomen was opened with a midline incision.", + "A solid mass was in the midline of the abdominal wall.", + "The mass was adhering to the rectus muscles and the fascia.", + "The mass was 12 cm in size.", + "The mass was dissected from the rectus muscles.", + "The mass was dissected from the peritoneum.", + "The mass was connected to the abdominal wall with a relatively thick bundle.", + "The bundle was 2 cm in size.", + "The bundle was in the suprapubic region.", + "The mass was similar to uterine fibroids in shape and consistency.", + "The visceral peritoneum was completely healthy.", + "The visceral peritoneum was opened to check the abdominal cavity.", + "No specific pathological findings were observed in the examination of the abdomen and pelvis.", + "The uterus and adnexa were completely healthy.", + "There was no evidence of adhesion.", + "There was no evidence of mass.", + "There was no evidence of ovarian cyst.", + "There was no evidence of uterine fibroids.", + "The surgery was terminated.", + "The pathology report of the abdominal wall mass was leiomyoma." + ], + "summary": "This case was a patient who became a candidate for laparoscopy due to abnormal uterine bleeding and pain in the right upper quadrant of the abdomen and ovarian mass. The patient underwent laparotomy due to the inability of surgeons to insert the veress needle because of the presence of mass in the abdominal wall. The pathologic report of the abdominal mass was leiomyoma. This article has been approved by the Ethics Committee of the University (6562276).", + "summary_subclaims": [ + "The patient became a candidate for laparoscopy due to abnormal uterine bleeding and pain in the right upper quadrant of the abdomen and ovarian mass.", + "The patient underwent laparotomy due to the inability of surgeons to insert the veress needle because of the presence of mass in the abdominal wall.", + "The pathologic report of the abdominal mass was leiomyoma.", + "This article has been approved by the Ethics Committee of the University (6562276)." + ] + }, + { + "id": "multiclinsum_test_961_en.txt", + "fulltext": "A 2-year history of primary infertility after marriage.\nThe patient was a 28-year-old female with a 2-year history of primary infertility after marriage. Her menstrual history was as follows: menarche at age 14, a cycle of 7/-30 days, normal volume and color of menstrual blood, and no dysmenorrhea. The male partner was 26 years old. Results of the routine semen analysis were normal (sperm concentration 34.7 × 106; percentage of progressive motility 64.6%; sperm DNA fragmentation index: 14.38%) according to World Health Organization 5th Edition criteria.\nIn 2019, the patient underwent hysteroscopy and hysteroscopic endometrial polypectomy at another hospital due to abnormal echoes in the uterine cavity, and pathological examination of the uterine specimen indicated the presence of endometrial polyps.\nThe patient had no pertinent personal or family history. Both partners had no bad living habits or hobbies, and were not engaged in work related to reproductive toxicity.\nThe patient had a negative vulva, a normal uterus, and a negative bilateral adnexal area. Her body mass index was 21.23 kg/m2.\nThe concentration of anti-Mullerian hormone (AMH) was 2.634 ng/mL (1 ng/mL = 7.14 pmol/L). There were no obvious abnormalities in basic hormone levels or thyroid function. The patient’s karyotype was 46, XX, and the male partner’s karyotype was 46, XY.\nHysterosalpingography revealed that the uterine cavity was normal, bilateral fallopian tubes were developed, and the spread of the pelvic contrast agent was diffuse and limited.", + "fulltext_subclaims": [ + "The patient was a 28-year-old female with a 2-year history of primary infertility after marriage.", + "Her menstrual history was as follows: menarche at age 14, a cycle of 7/-30 days, normal volume and color of menstrual blood, and no dysmenorrhea.", + "The male partner was 26 years old.", + "Results of the routine semen analysis were normal according to World Health Organization 5th Edition criteria.", + "Sperm concentration was 34.7 × 106.", + "Percentage of progressive motility was 64.6%.", + "Sperm DNA fragmentation index was 14.38%.", + "In 2019, the patient underwent hysteroscopy and hysteroscopic endometrial polypectomy at another hospital.", + "Pathological examination of the uterine specimen indicated the presence of endometrial polyps.", + "The patient had no pertinent personal or family history.", + "Both partners had no bad living habits or hobbies.", + "The patient had a negative vulva.", + "The uterus was normal.", + "The bilateral adnexal area was negative.", + "The patient’s body mass index was 21.23 kg/m2.", + "The concentration of anti-Mullerian hormone (AMH) was 2.634 ng/mL.", + "There were no obvious abnormalities in basic hormone levels or thyroid function.", + "The patient’s karyotype was 46, XX.", + "The male partner’s karyotype was 46, XY.", + "Hysterosalpingography revealed that the uterine cavity was normal.", + "Bilateral fallopian tubes were developed.", + "The spread of the pelvic contrast agent was diffuse and limited." + ], + "summary": "Here, we collected and described the clinical data of a patient with early embryonic development stagnation after repeated in vitro fertilization attempts for primary infertility at the Department Reproductive Center of Zaozhuang Maternal and Child Healthcare Hospital. We also detected the whole-exon gene of the patient's spouse and parents, and conducted bioinformatics analysis to determine the pathogenesis of the gene.", + "summary_subclaims": [ + "The patient had early embryonic development stagnation after repeated in vitro fertilization attempts.", + "The patient had primary infertility.", + "The clinical data were collected at the Department Reproductive Center of Zaozhuang Maternal and Child Healthcare Hospital.", + "The whole-exon gene of the patient's spouse was detected.", + "The whole-exon gene of the patient's parents was detected.", + "Bioinformatics analysis was conducted to determine the pathogenesis of the gene." + ] + }, + { + "id": "multiclinsum_test_1494_en.txt", + "fulltext": "A 69-year-old woman presented with hematuria during routine screening.\nComputed tomography (CT) urography was performed at the Department of Nephrology. Incidentally, a small bowel tumor was detected on the CT scan, prompting a referral to our department.\nThe patient had no other underlying diseases, except for hypertension, and did not complain of GI symptoms (such as nausea, vomiting, or abdominal pain). There was no history of previous pulmonary tuberculosis.\nThe patient had no relevant family history.\nA physical examination revealed normoactive bowel sounds, no abdominal distention, and no prominent tenderness. The vital signs were as follows: blood pressure, 141/86 mmHg; pulse rate, 70 beats/min; respiratory rate, 18 breaths/min; and body temperature, 36.2°C.\nLaboratory tests indicated anemia, with the following findings: hemoglobin, 9.2 g/dL (reference: 12–16 g/dL); mean corpuscular volume, 87.8 fL (reference: 80–100 fL); mean corpuscular hemoglobin, 29.8 pg (reference: 26–38 pg); serum iron, 82 μg/dL (reference: 29–164 μg/dL); ferritin, 116 ng/mL (reference: 13–150 ng/mL); and unsaturated iron binding capacity, 135 μg/dL (reference: 191–269 μg/dL). Tumor markers, namely carcinoembryonic antigen and carbohydrate antigen 19-9, were within their normal limits (0.697 ng/mL and 3.8 U/mL, respectively). No other abnormalities were noted.\nA CT scan revealed irregular thickening of the distal ileum, which caused proximal small bowel dilatation, and several enlarged lymph nodes in the mesentery and preaortic area . These findings suggested the presence of a malignant small bowel tumor with lymph node metastasis. No findings indicative of GI bleeding were observed during an endoscopic evaluation.", + "fulltext_subclaims": [ + "The patient is a 69-year-old woman.", + "She presented with hematuria during routine screening.", + "Computed tomography (CT) urography was performed at the Department of Nephrology.", + "A small bowel tumor was detected on the CT scan.", + "The patient had no other underlying diseases, except for hypertension.", + "The patient did not complain of GI symptoms.", + "There was no history of previous pulmonary tuberculosis.", + "The patient had no relevant family history.", + "A physical examination revealed normoactive bowel sounds.", + "The vital signs were as follows: blood pressure, 141/86 mmHg; pulse rate, 70 beats/min; respiratory rate, 18 breaths/min; and body temperature, 36.2°C.", + "Laboratory tests indicated anemia.", + "Hemoglobin was 9.2 g/dL.", + "Mean corpuscular volume was 87.8 fL.", + "Mean corpuscular hemoglobin was 29.8 pg.", + "Serum iron was 82 μg/dL.", + "Ferritin was 116 ng/mL.", + "Unsaturated iron binding capacity was 135 μg/dL.", + "Tumor markers, namely carcinoembryonic antigen and carbohydrate antigen 19-9, were within their normal limits.", + "A CT scan revealed irregular thickening of the distal ileum.", + "The CT scan showed proximal small bowel dilatation.", + "The CT scan showed several enlarged lymph nodes in the mesentery and preaortic area.", + "These findings suggested the presence of a malignant small bowel tumor with lymph node metastasis.", + "No findings indicative of GI bleeding were observed during an endoscopic evaluation." + ], + "summary": "The patient presented with an incidental finding of a small bowel tumor during computed tomography (CT) examination performed for hematuria. The CT scan showed irregular thickening of the distal ileum, which was suggestive of a malignant small bowel tumor. An exploratory laparotomy revealed an 8-cm mass in the distal ileum; thus, a segment of the small intestine, including the mass, was resected. Histopathological analysis revealed an ulceroinfiltrative mass-like lesion with luminal narrowing, marked inflammatory cell infiltration, and large atypical lymphoid cells (positive for EBV-encoded small RNA). A final diagnosis of an EBV-MCU was established. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. The patient remained recurrence-free until 12 mo after surgery.", + "summary_subclaims": [ + "The patient presented with an incidental finding of a small bowel tumor during computed tomography (CT) examination performed for hematuria.", + "The CT scan showed irregular thickening of the distal ileum.", + "The CT scan findings were suggestive of a malignant small bowel tumor.", + "An exploratory laparotomy revealed an 8-cm mass in the distal ileum.", + "A segment of the small intestine, including the mass, was resected.", + "Histopathological analysis revealed an ulceroinfiltrative mass-like lesion with luminal narrowing.", + "Histopathological analysis showed marked inflammatory cell infiltration.", + "Histopathological analysis showed large atypical lymphoid cells.", + "The large atypical lymphoid cells were positive for EBV-encoded small RNA.", + "A final diagnosis of an EBV-MCU was established.", + "The postoperative course was uneventful.", + "The patient was discharged on postoperative day 7.", + "The patient remained recurrence-free until 12 mo after surgery." + ] + }, + { + "id": "multiclinsum_test_828_en.txt", + "fulltext": "A 38-year-old Japanese woman, gravida 0, presented with abdominal distension and frequent urination, was found to have a pelvic mass on radiologic examinations. She had a history of laparoscopic uterine myomectomy about a year before the onset, where the bilateral ovaries were macroscopically normal . She had no menstrual irregularities or dysfunctional uterine bleeding. Serum estradiol (E2) level was elevated to 214.5 pg/ml (normal 70–160 pg/ml), while testosterone was within the normal range. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) were 2.0 mIU/ml (normal 1-14mIU/ml) and less than 0.1 mIU/ml (normal 1.5-8mIU/ml) respectively, indicating E2-mediated negative feedback. CA 125 level was slightly elevated to 39.2 U/ml (normal < 35.0 U/ml). CEA, CA 19–9 and SCC antigen were within the normal range.\nThe MR showed a large, multiloculated cystic mass with numerous septations in the pelvis measuring approximately 10 × 10 × 12 cm. On T2-weighted images, fluid-fluid levels were demonstrated in several cystic components . T1-weighted images demonstrated intracystic high signal intensities suggesting intracystic hemorrhage . Contrast-enhanced fat-suppressed T1-weighted images showed strong enhancement of the septations similar to uterine myometrium . The mass was suspected to originate from the right ovary because the right ovary was not identified. The left ovary was atrophic for her age . On diffusion-weighted imaging, the septations showed high signal intensity . The uterus was of normal size without endometrial thickening. There was a small amount of ascites which was limited to the pouch of Douglas and vesicouterine pouch . Any calcifications were not detected on CT images. GCT was suspected from these findings.\nAbdominal right ovarian tumor resection was performed. During the operation, the frozen section of the right ovarian tumor showed that malignancy could not be excluded due to its nuclear atypia. The differential diagnoses of the tumor included yolk sac tumor, malignant mucinous tumor and AGCT despite of the lack of any typical findings such as coffee-bean nuclei and Call-Exner bodies. Based on this report, abdominal simple total hysterectomy, bilateral oophoro-salpingectomy, partial omentectomy and appendectomy were performed.\nThe gross appearance of the cut surface of the right ovarian tumor, measuring 13 cm in diameter, showed multiloculated cystic tumor accompanied by intracystic hemorrhagic foci. The left ovary had a maximum diameter of 1.7 cm, suggesting atrophy for her age . Microscopic examination of the right ovary showed round cells that surrounded the macrofolliculars with eosinophilic material and hemorrhage .The tumor cells had scant cytoplasm, round-to-oval vesicular nuclei with small eosinophilic nucleoli, and irregular nuclear contours. The typical findings for AGCT such as longitudinal nuclear grooves (coffee-bean nuclei) and Call-Exner bodies were not identified. The mitotic activity was focally brisk, with an average of 10 mitoses per 10 high-power fields in these areas . Immunohistochemically, tumor cells were positive for vimentin, calretinin, CD99, a-inhibin and MIB-1 labeling index was about 30%. The above findings supported the diagnosis of JGCT. Accordingly, the definitive diagnosis of JGCT, FIGO Stage IA led to no additional treatment.", + "fulltext_subclaims": [ + "The patient is a 38-year-old Japanese woman.", + "She had a history of laparoscopic uterine myomectomy about a year before the onset.", + "The bilateral ovaries were macroscopically normal at the time of the myomectomy.", + "She had no menstrual irregularities.", + "She had no dysfunctional uterine bleeding.", + "Serum estradiol (E2) level was 214.5 pg/ml.", + "The normal range for estradiol is 70–160 pg/ml.", + "Luteinizing hormone (LH) was 2.0 mIU/ml.", + "The normal range for LH is 1-14 mIU/ml.", + "Follicle stimulating hormone (FSH) was less than 0.1 mIU/ml.", + "The normal range for FSH is 1.5-8 mIU/ml.", + "The MR showed a large, multiloculated cystic mass with numerous septations in the pelvis.", + "The mass measured approximately 10 × 10 × 12 cm.", + "T2-weighted images demonstrated fluid-fluid levels in several cystic components.", + "T1-weighted images showed intracystic high signal intensities suggesting intracystic hemorrhage.", + "Contrast-enhanced fat-suppressed T1-weighted images showed strong enhancement of the septations similar to uterine myometrium.", + "The mass was suspected to originate from the right ovary because the right ovary was not identified.", + "The left ovary was atrophic for her age.", + "Diffusion-weighted imaging showed high signal intensity in the septations.", + "The uterus was of normal size.", + "There was a small amount of ascites limited to the pouch of Douglas and vesicouterine pouch.", + "Any calcifications were not detected on CT images.", + "GCT was suspected from these findings.", + "Abdominal right ovarian tumor resection was performed.", + "The frozen section of the right ovarian tumor showed malignancy could not be excluded due to its nuclear atypia.", + "The differential diagnoses included yolk sac tumor, malignant mucinous tumor, and AGCT.", + "The typical findings for AGCT such as coffee-bean nuclei and Call-Exner bodies were not identified.", + "The gross appearance of the right ovarian tumor showed multiloculated cystic tumor accompanied by intracystic hemorrhagic foci.", + "The left ovary had a maximum diameter of 1.7 cm, suggesting atrophy for her age.", + "Microscopic examination showed round cells that surrounded macrofolliculars with eosinophilic material and hemorrhage.", + "The tumor cells had scant cytoplasm, round-to-oval vesicular nuclei with small eosinophilic nucleoli, and irregular nuclear contours.", + "The typical findings for AGCT such as coffee-bean nuclei and Call-Exner bodies were not identified.", + "The mitotic activity was focally brisk, with an average of 10 mitoses per 10 high-power fields in these areas.", + "Immunohistochemically, tumor cells were positive for vimentin, calretinin, CD99, and a-inhibin.", + "The MIB-1 labeling index was about 30%.", + "The definitive diagnosis was JGCT, FIGO Stage IA.", + "No additional treatment was given." + ], + "summary": "A 38-year-old woman, presented with abdominal distension and frequent urination, was found to have a pelvic mass measuring approximately 12 cm on ultrasonography. On magnetic resonance imaging (MRI), right ovarian multiloculated cystic mass accompanied with hemorrhagic foci was demonstrated. Although the presumptive diagnosis of GCT was made based on MR findings, the intraoperative differential diagnoses included GCT, yolk sac tumor or malignant mucinous tumor due to cytologic atypia and lack of the typical findings for AGCT such as nuclear grooves and Call-Exner bodies. As a result, abdominal simple total hysterectomy, bilateral oophoro-salpingectomy, partial omentectomy and appendectomy were performed. Moreover, she had a history of laparoscopic uterine myomectomy about one year before, and during that surgery bilateral ovaries were found to be macrospically normal. Therefore, it was suspected the tumor became enlarged within the short period of time.", + "summary_subclaims": [ + "The patient is a 38-year-old woman.", + "She presented with abdominal distension and frequent urination.", + "A pelvic mass measuring approximately 12 cm was found on ultrasonography.", + "On MRI, a right ovarian multiloculated cystic mass accompanied with hemorrhagic foci was demonstrated.", + "The presumptive diagnosis of GCT was made based on MR findings.", + "The intraoperative differential diagnoses included GCT, yolk sac tumor, or malignant mucinous tumor.", + "The differential diagnoses were due to cytologic atypia and lack of the typical findings for AGCT such as nuclear grooves and Call-Exner bodies.", + "Abdominal simple total hysterectomy was performed.", + "Bilateral oophoro-salpingectomy was performed.", + "Partial omentectomy was performed.", + "Appendectomy was performed.", + "She had a history of laparoscopic uterine myomectomy about one year before.", + "During the myomectomy, bilateral ovaries were found to be macroscopically normal.", + "It was suspected the tumor became enlarged within the short period of time." + ] + }, + { + "id": "multiclinsum_test_2029_en.txt", + "fulltext": "A 52-year-old Caucasian woman with a past medical history of severe hypertension and non-insulin dependent diabetes mellitus presented with bilateral subacute visual loss which progressed over eight to 10 days to perceiving only light in the left eye and only hand movements in the right eye. The visual loss was preceded by dull ocular pain which persisted after the onset of visual loss. The patient experienced pain on eye movements but had no double vision. The patient did not have any temporal artery tenderness and temporal pulses were palpable bilaterally.\nOn fundoscopic examination, both optic discs were swollen and no retinopathic changes of diabetes or hypertension were evident. There was no evidence of venous engorgement. There was reduced color vision in both eyes and a left relative afferent papillary defect was present. Visual field mapping showed a left central scotoma and a normal right sided visual field. The patient's blood pressure was 152/80 on admission and lower on subsequent readings during her hospital stay. The remaining neurological examination was unremarkable. There was nothing in her history or physical examination suggestive of connective tissue disease or sarcoidosis. Initial blood tests showed a normal full blood count, normal urea and electrolytes (U&Es), normal liver function tests, a normal C-reactive protein (CRP; < 1) and plasma viscosity and a raised glycated haemoglobin (HbA1c) of 7.3% (normal 4 to 6.1). Chest X-ray was normal. A lumbar puncture was performed which yielded cerebrospinal fluid (CSF) with normal white and red blood cells, a normal angiotension converting enzyme (ACE) level, no oligoclonal bands and a marginally elevated protein level of 467.7 mg/L (normal 150 to 450 mg/L). A magnetic resonance imaging (MRI) scan of her brain and spinal cord was normal.\nA provisional diagnosis of acute ischaemic optic neuropathy was made by the general medical team and the patient was started on aspirin with omeprazole cover. On review by the neurology team a day later the cause was thought to be inflammatory rather than ischemic. She received a three day course of intravenous methyl prednisolone. Vision improved to 6/6 in both eyes within two days with full restoration of color vision and visual field defects. Ten days later however, vision deteriorated again in the right eye to 6/36 with a temporal peripheral field loss. The relative afferent papillary defect had now switched to the right eye. The patient received 500 mg oral methyl prednisolone for five days. Her visual acuity and visual fields returned to normal within two days.\nA subsequent auto-immunity screen including aquaporin-4 antibodies was negative. Visual evoked potentials performed twelve days after the onset of the second episode of visual loss were delayed bilaterally (left > right) indicating bilateral optic nerve dysfunction. Her pattern electroretinograms, brainstem evoked potentials, median nerve and posterior tibial somatosensory evoked potentials were normal bilaterally.\nThere was no evidence of Leber's hereditary optic neuropathy on genetic molecular analysis. The m.11778G > A, m.3460G > A, m.14484T > C mitochondrial mutations were tested for and not detected in our patient.\nA chest computed tomography (CT) was normal and did not show any hilar adenopathy or any other features of sarcoidosis.\nSerial MRIs over the next four months were normal without any inflammatory lesions and oligoclonal bands were negative which excluded multiple sclerosis.", + "fulltext_subclaims": [ + "The patient is a 52-year-old Caucasian woman.", + "She has a past medical history of severe hypertension.", + "She has non-insulin dependent diabetes mellitus.", + "She presented with bilateral subacute visual loss.", + "The visual loss progressed over eight to 10 days.", + "She perceived only light in the left eye.", + "She perceived only hand movements in the right eye.", + "The visual loss was preceded by dull ocular pain.", + "The ocular pain persisted after the onset of visual loss.", + "She experienced pain on eye movements.", + "She had no double vision.", + "She did not have any temporal artery tenderness.", + "Temporal pulses were palpable bilaterally.", + "On fundoscopic examination, both optic discs were swollen.", + "There were no retinopathic changes of diabetes.", + "There were no retinopathic changes of hypertension.", + "There was no evidence of venous engorgement.", + "There was reduced color vision in both eyes.", + "A left relative afferent papillary defect was present.", + "Visual field mapping showed a left central scotoma.", + "The right-sided visual field was normal.", + "The patient's blood pressure was 152/80 on admission.", + "The remaining neurological examination was unremarkable.", + "There was nothing in her history or physical examination suggestive of connective tissue disease.", + "There was nothing in her history or physical examination suggestive of sarcoidosis.", + "Initial blood tests showed a normal full blood count.", + "Initial blood tests showed normal urea and electrolytes.", + "Initial blood tests showed normal liver function tests.", + "Initial blood tests showed a normal C-reactive protein.", + "Initial blood tests showed a normal plasma viscosity.", + "Initial blood tests showed a raised glycated haemoglobin of 7.3%.", + "A chest X-ray was normal.", + "A lumbar puncture was performed.", + "Cerebrospinal fluid had normal white and red blood cells.", + "Cerebrospinal fluid had a normal angiotension converting enzyme level.", + "Cerebrospinal fluid had no oligoclonal bands.", + "Cerebrospinal fluid had a marginally elevated protein level of 467.7 mg/L.", + "A magnetic resonance imaging scan of her brain and spinal cord was normal.", + "A provisional diagnosis of acute ischaemic optic neuropathy was made.", + "The patient was started on aspirin with omeprazole cover.", + "On review by the neurology team, the cause was thought to be inflammatory rather than ischemic.", + "She received a three day course of intravenous methyl prednisolone.", + "Vision improved to 6/6 in both eyes within two days.", + "Color vision was fully restored.", + "Visual field defects were fully restored.", + "Ten days later, vision deteriorated again in the right eye to 6/36.", + "There was a temporal peripheral field loss.", + "The relative afferent papillary defect had now switched to the right eye.", + "The patient received 500 mg oral methyl prednisolone for five days.", + "Visual acuity and visual fields returned to normal within two days.", + "A subsequent auto-immunity screen including aquaporin-4 antibodies was negative.", + "Visual evoked potentials performed twelve days after the onset of the second episode of visual loss were delayed bilaterally.", + "Visual evoked potentials indicated bilateral optic nerve dysfunction.", + "Pattern electroretinograms were normal bilaterally.", + "Brainstem evoked potentials were normal bilaterally.", + "Median nerve somatosensory evoked potentials were normal bilaterally.", + "Posterior tibial somatosensory evoked potentials were normal bilaterally.", + "There was no evidence of Leber's hereditary optic neuropathy on genetic molecular analysis.", + "The m.11778G > A mitochondrial mutation was not detected.", + "The m.3460G > A mitochondrial mutation was not detected.", + "The m.14484T > C mitochondrial mutation was not detected.", + "A chest computed tomography was normal.", + "The chest CT did not show any hilar adenopathy.", + "Serial MRIs over the next four months were normal.", + "There were no inflammatory lesions on serial MRIs.", + "Oligoclonal bands were negative.", + "Multiple sclerosis was excluded." + ], + "summary": "We describe the case of a 52-year-old Caucasian woman who presented with isolated subacute optic neuropathy. There was no evidence of demyelination, autoimmunity or sarcoidosis. There was an abrupt and prompt response to systemic corticosteroids and a relapse of the condition on steroid withdrawal.", + "summary_subclaims": [ + "The patient was a 52-year-old Caucasian woman.", + "The patient presented with isolated subacute optic neuropathy.", + "There was no evidence of demyelination.", + "There was no evidence of autoimmunity.", + "There was no evidence of sarcoidosis.", + "There was an abrupt and prompt response to systemic corticosteroids.", + "There was a relapse of the condition on steroid withdrawal." + ] + }, + { + "id": "multiclinsum_test_811_en.txt", + "fulltext": "A 51 year-old male veteran presented with progressive lethargy, fevers and constant frontotemporal headache for past 3 weeks as well as 20 pound weight loss in past 6 months. Born in Guam, the patient had been stationed as part of the military in Texas, Arizona and Kansas. His medical history was notable for polycythemia vera (PCV) treated with ruxolitinib for 18 months. Three months before admission, he had recurrent mouth ulcers, followed by a dental root canal procedure complicated by ulcerative gingivitis, pulpitis and tooth erosions requiring antibiotics and multiple oral surgeries. All antimicrobials had been discontinued over a month prior to presentation.\nOn admission the patient was febrile to 103.5 °F, tachycardic, and saturating 95% on 2 l of oxygen by nasal cannula. Physical exam revealed somnolence, diminished breath sounds at the left lung base and diffuse abdominal tenderness. Neurologic exam identified no focal deficits. Initial laboratory studies (normal range) revealed hyponatremia to 125 (136–145) mmol/L and a creatinine elevation to 1.8 (0.67–1.17) mg/dL. He also had an elevated alkaline phosphatase of 208 (35–140) U/L and total bilirubin of 1.6 (< 1.2) mg/dL. White cell count was 8002 (4000-10,000) cells/mm3 with 74% polymorphonuclear cells and 13% lymphocytes. The C-reactive protein level was 3.89 (< 0.5) mg/dL and the erythrocyte sedimentation rate was 36 (< 30) mm/hr. Rapid HIV antibody testing, as well as HIV viral load, were negative.\nThe brain MRI revealed innumerable rim enhancing lesions at the gray-white junction consistent with pyogenic abscesses secondary to hematogenous infection . A lumbar puncture revealed 10 mononuclear cells and 9 polymorphonuclear cells/ml CSF. Glucose was 27 (40–70) mg/dL and protein was 72 (15–45) mg/dL. Vancomycin, ceftriaxone and metronidazole were initiated empirically.\nThe patient subsequently underwent chest and abdominal CT examinations to evaluate diminished breath sounds and abdominal tenderness. A retrocardiac mass was seen measuring 2.7 cm as well as bilaterally enlarged adrenal glands consistent with infiltrative infection or neoplasm.\nCSF cultures grew no bacteria; however, cryptococcal antigen was detected with titer of 1:> 256 in CSF and 1:128 in the serum. Fungal CSF cultures grew Cryptococcus neoformans. An adrenal biopsy performed by interventional radiology revealed numerous fungal organisms on histopathology. Gomorri methenamine silver (GMS) and periodic acid-Schiff (PAS) stains highlighted budding yeast forms within macrophages, most consistent with histoplasmosis. Histoplasma capsulatum subsequently grew in fungal blood cultures. Histoplasma antigen was 11.9 (< 0.5) ng/mL in urine, 8.46 (< 0.4) ng/mL in the serum and 1.86 (< 0.4) ng/mL in CSF. Cryptococcal susceptibilities ultimately returned with an MIC of < 0.03 μg/ml to isavuconazole and 0.25 μg/ml to posaconazole; Histoplasma susceptibilities were < 0.03 μg/ml to both isavuconazole and posaconazole. The patient was diagnosed with concurrent cryptococcal meningitis as well as disseminated histoplasmosis.\nAmphotericin infusion as Ambisome at 5 mg/kg every 48 h with flucytosine 1 g q6hrs were initiated for treatment of both identified fungal organisms with improvement of symptoms. Given limited evidence of the successful use of the newer azoles, posaconazole [–] and isavuconazole [–] for CNS disease, the patient was continued on amphotericin infusions for three months and transitioned to 372 mg isavuconazole daily when renal toxicity was noted with Ambisome. A follow up MRI at that time demonstrated diminishing rim-enhancing lesions. The retrocardiac mass was smaller in size on repeat imaging; however, the appearance of the adrenal glands remained unchanged. Cryptococcal antigen titers were 1:16 in serum and 1:8 in CSF. Histoplasmosis antigen in the urine was 0.83 (< 0.5) ng/mL and was no longer detected in the serum. A biopsy of the brain lesions was not performed; however, we hypothesized that the brain lesions were caused by hematogenous spread of histoplasmosis to the gray-white junction with resulting granuloma formation. At the time this case report was written, the patient was still being treated with isavuconazole.\nOf note, once the patient was diagnosed with the two fungal infections, ruxolitinib was discontinued. Given the severity of his presentation, his primary oncologist believed that a re-challenge with ruxolitinib was contraindicated.\nAfter further discussion with the patient, he had recollected a 2 cm ulcerative, painful tongue mass that first appeared three months after initiating ruxolitinib. This had been biopsied in the past and was not malignant, but had not been evaluated with fungal culture. Retrospective review of the pathology slides was suggestive of histoplasmosis, with small budding yeast forms noted within granulomas on GMS stain .", + "fulltext_subclaims": [ + "The patient is a 51 year-old male veteran.", + "He had progressive lethargy, fevers, and constant frontotemporal headache for past 3 weeks.", + "He had 20 pound weight loss in past 6 months.", + "He was born in Guam.", + "He had been stationed in Texas, Arizona, and Kansas.", + "His medical history was notable for polycythemia vera treated with ruxolitinib for 18 months.", + "Three months before admission, he had recurrent mouth ulcers.", + "He had a dental root canal procedure complicated by ulcerative gingivitis, pulpitis, and tooth erosions.", + "All antimicrobials had been discontinued over a month prior to presentation.", + "On admission, he was febrile to 103.5 °F.", + "He was tachycardic and saturating 95% on 2 l of oxygen by nasal cannula.", + "Physical exam revealed somnolence.", + "Initial laboratory studies revealed hyponatremia to 125 mmol/L.", + "Creatinine was elevated to 1.8 mg/dL.", + "Alkaline phosphatase was 208 U/L.", + "Total bilirubin was 1.6 mg/dL.", + "White cell count was 8002 cells/mm3.", + "C-reactive protein level was 3.89 mg/dL.", + "Rapid HIV antibody testing was negative.", + "HIV viral load was negative.", + "The brain MRI revealed innumerable rim enhancing lesions at the gray-white junction.", + "A lumbar puncture revealed 10 mononuclear cells and 9 polymorphonuclear cells/ml CSF.", + "CSF glucose was 27 mg/dL.", + "CSF protein was 72 mg/dL.", + "Vancomycin, ceftriaxone, and metronidazole were initiated empirically.", + "A retrocardiac mass measuring 2.7 cm was seen on CT.", + "Bilaterally enlarged adrenal glands were seen.", + "CSF cultures grew no bacteria.", + "Cryptococcal antigen was detected with titer of 1:> 256 in CSF.", + "Fungal CSF cultures grew Cryptococcus neoformans.", + "An adrenal biopsy revealed numerous fungal organisms on histopathology.", + "GMS and PAS stains highlighted budding yeast forms within macrophages.", + "Histoplasma capsulatum subsequently grew in fungal blood cultures.", + "Histoplasma antigen was 11.9 ng/mL in urine.", + "Histoplasma antigen was 8.46 ng/mL in serum.", + "Histoplasma antigen was 1.86 ng/mL in CSF.", + "Cryptococcal susceptibilities returned with an MIC of < 0.03 μg/ml to isavuconazole.", + "Cryptococcal susceptibilities returned with an MIC of 0.25 μg/ml to posaconazole.", + "Histoplasma susceptibilities were < 0.03 μg/ml to both isavuconazole and posaconazole.", + "The patient was diagnosed with concurrent cryptococcal meningitis and disseminated histoplasmosis.", + "Amphotericin infusion as Ambisome at 5 mg/kg every 48 h with flucytosine 1 g q6hrs were initiated.", + "The patient was transitioned to 372 mg isavuconazole daily when renal toxicity was noted.", + "A follow up MRI demonstrated diminishing rim-enhancing lesions.", + "The retrocardiac mass was smaller in size on repeat imaging.", + "Cryptococcal antigen titers were 1:16 in serum and 1:8 in CSF.", + "Histoplasmosis antigen in the urine was 0.83 ng/mL.", + "Histoplasmosis antigen was no longer detected in the serum.", + "A biopsy of the brain lesions was not performed.", + "We hypothesized that the brain lesions were caused by hematogenous spread of histoplasmosis.", + "At the time this case report was written, the patient was still being treated with isavuconazole.", + "Ruxolitinib was discontinued after the patient was diagnosed with the two fungal infections.", + "The patient had recollected a 2 cm ulcerative, painful tongue mass that first appeared three months after initiating ruxolitinib.", + "The tongue mass had been biopsied in the past and was not malignant.", + "Retrospective review of the pathology slides was suggestive of histoplasmosis.", + "Small budding yeast forms were noted within granulomas on GMS stain." + ], + "summary": "We report the case of a 51 year-old veteran from Guam, treated with ruxolitinib for polycythemia vera, who developed disseminated histoplasmosis and concurrent cryptococcal meningitis.", + "summary_subclaims": [ + "The patient was a 51 year-old veteran from Guam.", + "The patient was treated with ruxolitinib.", + "The patient had polycythemia vera.", + "The patient developed disseminated histoplasmosis.", + "The patient developed concurrent cryptococcal meningitis." + ] + }, + { + "id": "multiclinsum_test_1655_en.txt", + "fulltext": "A 35-year-old Caucasian male presented to the Maxillofacial Surgery service of Campo Limpo Hospital, in São Paulo, Brazil, with the main complaint of an intraoral swelling that had been growing for the last 8 years. The lesion was asymptomatic, and even though the patient had been aware of its constant growth, he decided to look for professional help only when its proportion began to cause him speaking impairment.\nThe physical examination revealed a firm mushroom-like mass, with bony consistency covered by smooth regular mucosa spanning almost the entire right alveolar border of the mandible. The area was edentulous and, according to the patient’s report, had initiated its growth shortly after the extraction of a molar, which the patient could not specify. As it developed, the remaining teeth had been extruded until complete avulsion (teeth 28 through 32, in universal numbering system). No extraoral abnormalities were observed. The patient was in good health, with no history of previous diseases, smoking, or substance abuse. The diagnosis of Gardner syndrome was discarded due to the lack of any other symptoms, such as gastrointestinal implications or supernumerary teeth .\nComputed tomography revealed a well-defined pedunculated mass attached to the right body of the mandible with radiographic characteristics resembling the original bone, consisting of a central area of moderated radiopacity similar to medullary bone, surrounded by a denser, more radiopaque thin area, comparable to cortical bone. According to Rodriguez (2011), these particular growth characteristics make it easy to diagnose a peripheral osteoma clinically and radiographically .\nSince the tumor presented both clinical and radiographic features of a benign lesion, the patient underwent an excisional biopsy, with complete removal of the mass and an osteoplasty of the mandible. The access was intraoral, with an incision directly over the lesion, and divulsion of the mucoperiosteal tissues, preserving their integrity for suture later . After the complete exposure of the lesion, surgical drills were used to mark the limits of excision, and the mass was removed in two pieces, with the use of a chisel and hammer. An oval drill was used to perform an osteoplasty of the jaw, recovering its original shape and thickness . After surgical resection, the mucosa flaps had their wedges trimmed, to obtain straight margins that were sutured with 3–0 resorbable thread. The surgical piece was a white, oval, bony fragment, with a regular surface of approximately 4.2 × 4.8 × 2.5 cm . The postoperative course was uneventful, except for discrete dehiscence of the suture 5 days after the procedure, which was spontaneously healed with chlorhexidine mouthwash on clinical follow-up for the next 7 days . The radiographic aspect of the jaw, 14 days after surgery showing regular shape and dimensions .\nHistopathological analysis revealed mature adipose tissue, permeated by viable compact bone lamellae, consisting of medullary tissue, delimited by a thin and well-vascularized lamellar cortical bone. Thin and congested blood vessels were noted throughout the whole sample.", + "fulltext_subclaims": [ + "The patient is a 35-year-old Caucasian male.", + "He presented to the Maxillofacial Surgery service of Campo Limpo Hospital, in São Paulo, Brazil.", + "The main complaint was an intraoral swelling that had been growing for the last 8 years.", + "The lesion was asymptomatic.", + "The patient decided to seek professional help when the lesion began to cause speaking impairment.", + "The physical examination revealed a firm mushroom-like mass.", + "The mass had bony consistency covered by smooth regular mucosa.", + "The mass spanned almost the entire right alveolar border of the mandible.", + "The area was edentulous.", + "The patient reported the growth began shortly after the extraction of a molar.", + "The patient could not specify which molar was extracted.", + "The remaining teeth had been extruded until complete avulsion (teeth 28 through 32).", + "No extraoral abnormalities were observed.", + "The patient was in good health.", + "The patient had no history of previous diseases.", + "The patient had no history of smoking.", + "The patient had no history of substance abuse.", + "The diagnosis of Gardner syndrome was discarded.", + "Computed tomography revealed a well-defined pedunculated mass attached to the right body of the mandible.", + "The radiographic characteristics resembled the original bone.", + "The central area of the mass had moderated radiopacity similar to medullary bone.", + "The mass was surrounded by a denser, more radiopaque thin area comparable to cortical bone.", + "According to Rodriguez (2011), these growth characteristics make it easy to diagnose a peripheral osteoma clinically and radiographically.", + "The tumor presented both clinical and radiographic features of a benign lesion.", + "The patient underwent an excisional biopsy.", + "The mass was completely removed.", + "An osteoplasty of the mandible was performed.", + "The access was intraoral, with an incision directly over the lesion.", + "The mucoperiosteal tissues were divulsed, preserving their integrity for suture later.", + "Surgical drills were used to mark the limits of excision.", + "The mass was removed in two pieces, with the use of a chisel and hammer.", + "An oval drill was used to perform an osteoplasty of the jaw.", + "The surgical piece was a white, oval, bony fragment with a regular surface of approximately 4.2 × 4.8 × 2.5 cm.", + "The postoperative course was uneventful, except for discrete dehiscence of the suture 5 days after the procedure.", + "The dehiscence was spontaneously healed with chlorhexidine mouthwash on clinical follow-up for the next 7 days.", + "The radiographic aspect of the jaw, 14 days after surgery, showed regular shape and dimensions.", + "Histopathological analysis revealed mature adipose tissue.", + "The tissue was permeated by viable compact bone lamellae.", + "The bone lamellae consisted of medullary tissue.", + "The tissue was delimited by a thin and well-vascularized lamellar cortical bone.", + "Thin and congested blood vessels were noted throughout the whole sample." + ], + "summary": "A 35-year-old Caucasian man presenting a tumor lesion in the right jawbone that had been growing for 8 years sought medical service complaining of speaking impairment. According to the patient, the tumor appeared shortly after a minor trauma caused by tooth extraction. The diagnosis of the lesion was made through clinical, radiographic, and histological methods, and the surgical treatment was successful and satisfactory for the patient as well as the surgical team, despite a short follow-up.", + "summary_subclaims": [ + "A 35-year-old Caucasian man presented with a tumor lesion in the right jawbone.", + "The tumor lesion had been growing for 8 years.", + "The patient complained of speaking impairment.", + "The tumor appeared shortly after a minor trauma caused by tooth extraction.", + "The diagnosis of the lesion was made through clinical, radiographic, and histological methods.", + "The surgical treatment was successful.", + "The surgical treatment was satisfactory for the patient.", + "The surgical treatment was satisfactory for the surgical team.", + "The follow-up was short." + ] + }, + { + "id": "multiclinsum_test_1479_en.txt", + "fulltext": "A 47-year-old Caucasian man with a past medical history significant for noninsulin-dependent diabetes mellitus, hepatitis C, past alcohol abuse and cirrhosis was admitted to our medical intensive care unit with an upper gastrointestinal bleed. On presentation, his blood pressure was 104/70mmHg, heart rate 137 beats per minute, temperature 37.2°C and respiratory rate 24 breaths per minute. On examination, he was pale and icteric, and had a mildly distended abdomen with no discernable organomegaly. Cardio-respiratory examination was normal. He was confused and agitated with no focal neurological signs. His white blood count was elevated at 23.7 × 109//L with 24% bands, with a hemoglobin of 78g/L and platelets of 83 × 109/L. Albumin was 19g/dl (normal 32 to 49g/L), total bilirubin 83.3μmol/L (normal 3.4 to 20.4μmol/L), aspartate aminotransferase (AST) 32 IU/L (normal 7 to 42 IU/L), alanine aminotransferase (ALT) 35 IU/L (normal 1 to 45 IU/L), alkaline phosphatase (ALP) 32 IU/L (normal 25 to 120 IU/L), international normalized ratio (INR) of 1.84, arterial ammonia 151μmol/L (normal 11 to 35μmol/L) and lactate of 6.1mmol/L (normal 0.6 to 1.7mmol/L). His blood urea nitrogen (BUN) and creatinine were 9mmol/L and 124μmol/L, respectively.\nThe patient was electively intubated for airway protection and to facilitate endoscopy. He was resuscitated with crystalloids, 5% albumin, packed cells and fresh frozen plasma and treated with vancomycin and piperacillin/tazobactam for presumed sepsis. Ultrasound and Doppler of his upper quadrants was consistent with cirrhosis with normal blood flow and splenomegaly. An upper endoscopy revealed grade 4 esophageal varices with no active bleed. Over the next few days, the patient became progressively unresponsive (off sedation) with his ammonia level rising above 200μmol/L despite aggressive treatment with lactulose and rifaximin. Neurologic assessment revealed posturing to painful stimuli with a poorly reactive pupillary reflex. Computed tomography of the head revealed diffuse white matter edema prominent in the posterior temporal, parietal and occipital lobes. Brain MRI confirmed diffuse white matter edema with temporal and occipital lobe predominance consistent with the diagnostic pattern for PRES . His course was complicated by the development of tonic-clonic seizures which were controlled with intravenous levetiracetam. His pupils became fixed and non-responsive. Transcranial Dopplers (TCD) of the middle and posterior cerebral arteries demonstrated a marked reduction in cerebral blood velocity consistent with severely increased intracerebral pressure (ICP). As an extraordinary salvage method to control the patient's severe ICP, we lowered his core body temperature to 32°C with the addition of propofol and mannitol, titrated to keep serum osmolarity < 310mmol/L. Induced hypothermia was maintained for 48 hours during which time he regained normal pupillary reflexes with marked improvement in TCD velocities. During the passive rewarming phase, the patient developed massive hematemesis. He required massive transfusion and Minnesota tube placement as attempted banding via endoscopy was unsuccessful. The patient underwent an emergency transjugular intrahepatic portocaval shunt (TIPS) placement followed by repeat induced hypothermia (32 to 34°C). Due to the anticipated increase in the serum ammonia level following the massive gastrointestinal hemorrhage, we initiated high-flow continuous venovenous hemodiafiltration (CVVHD) to facilitate ammonia removal. The CVVHD was associated with a fall in the ammonia level . At this time, the patient was again passively rewarmed and the propofol discontinued. His neurological status improved slowly over the following week becoming more alert and responsive and allowing extubation. A repeat MRI of the brain showed interval improvement in extensive white matter signal abnormality most consistent with resolving PRES. He was discharged home with no neurological sequela apart from amnesia for the entire hospital stay. The patient has returned to work part-time and is currently listed for liver transplantation.", + "fulltext_subclaims": [ + "The patient was a 47-year-old Caucasian man.", + "He had a past medical history significant for noninsulin-dependent diabetes mellitus.", + "He had a past medical history of hepatitis C.", + "He had a past medical history of past alcohol abuse.", + "He had a past medical history of cirrhosis.", + "He was admitted to the medical intensive care unit with an upper gastrointestinal bleed.", + "On presentation, his blood pressure was 104/70mmHg.", + "On presentation, his heart rate was 137 beats per minute.", + "On presentation, his temperature was 37.2°C.", + "On presentation, his respiratory rate was 24 breaths per minute.", + "On examination, he was pale.", + "On examination, he was icteric.", + "On examination, he had a mildly distended abdomen.", + "On examination, there was no discernable organomegaly.", + "Cardio-respiratory examination was normal.", + "He was confused and agitated.", + "He had no focal neurological signs.", + "His white blood count was 23.7 × 109//L.", + "His hemoglobin was 78g/L.", + "His platelets were 83 × 109/L.", + "His albumin was 19g/dl.", + "His total bilirubin was 83.3μmol/L.", + "His AST was 32 IU/L.", + "His ALT was 35 IU/L.", + "His ALP was 32 IU/L.", + "His INR was 1.84.", + "His arterial ammonia was 151μmol/L.", + "His lactate was 6.1mmol/L.", + "His BUN was 9mmol/L.", + "His creatinine was 124μmol/L.", + "The patient was electively intubated for airway protection.", + "The patient was electively intubated to facilitate endoscopy.", + "He was resuscitated with crystalloids.", + "He was resuscitated with 5% albumin.", + "He was resuscitated with packed cells.", + "He was resuscitated with fresh frozen plasma.", + "He was treated with vancomycin for presumed sepsis.", + "He was treated with piperacillin/tazobactam for presumed sepsis.", + "An ultrasound and Doppler of his upper quadrants was consistent with cirrhosis.", + "An ultrasound and Doppler of his upper quadrants showed normal blood flow.", + "An ultrasound and Doppler of his upper quadrants showed splenomegaly.", + "An upper endoscopy revealed grade 4 esophageal varices.", + "An upper endoscopy showed no active bleed.", + "The patient became progressively unresponsive.", + "The patient's ammonia level rose above 200μmol/L.", + "The patient was treated with lactulose.", + "The patient was treated with rifaximin.", + "Neurologic assessment revealed posturing to painful stimuli.", + "Neurologic assessment showed a poorly reactive pupillary reflex.", + "Computed tomography of the head revealed diffuse white matter edema.", + "Computed tomography showed diffuse white matter edema prominent in the posterior temporal, parietal and occipital lobes.", + "Brain MRI confirmed diffuse white matter edema.", + "Brain MRI showed temporal and occipital lobe predominance.", + "The MRI findings were consistent with the diagnostic pattern for PRES.", + "The patient developed tonic-clonic seizures.", + "The seizures were controlled with intravenous levetiracetam.", + "The patient's pupils became fixed and non-responsive.", + "Transcranial Dopplers showed a marked reduction in cerebral blood velocity.", + "The reduction in cerebral blood velocity was consistent with severely increased intracerebral pressure.", + "The patient's core body temperature was lowered to 32°C.", + "Propofol was added to the treatment.", + "Mannitol was titrated to keep serum osmolarity < 310mmol/L.", + "Induced hypothermia was maintained for 48 hours.", + "The patient regained normal pupillary reflexes.", + "There was marked improvement in TCD velocities.", + "During the passive rewarming phase, the patient developed massive hematemesis.", + "The patient required massive transfusion.", + "Minnesota tube placement was performed.", + "Attempted banding via endoscopy was unsuccessful.", + "The patient underwent an emergency transjugular intrahepatic portocaval shunt (TIPS) placement.", + "Repeat induced hypothermia was performed.", + "The repeat induced hypothermia was maintained at 32 to 34°C.", + "High-flow continuous venovenous hemodiafiltration (CVVHD) was initiated.", + "The CVVHD was associated with a fall in the ammonia level.", + "The patient was passively rewarmed.", + "Propofol was discontinued.", + "The patient's neurological status improved.", + "The patient became more alert.", + "The patient became more responsive.", + "Extubation was allowed.", + "A repeat MRI showed interval improvement in extensive white matter signal abnormality.", + "The repeat MRI findings were most consistent with resolving PRES.", + "The patient was discharged home.", + "The patient had no neurological sequela apart from amnesia for the entire hospital stay.", + "The patient returned to work part-time.", + "The patient is currently listed for liver transplantation." + ], + "summary": "We report a 47-year-old Caucasian man with liver cirrhosis who developed posterior reversible encephalopathy syndrome following an upper gastrointestinal hemorrhage and who was managed with induced hypothermia for control of intracranial hypertension and continuous veno-venous hemodiafiltration for severe hyperammonemia.", + "summary_subclaims": [ + "The patient is a 47-year-old Caucasian man.", + "The patient has liver cirrhosis.", + "The patient developed posterior reversible encephalopathy syndrome.", + "The posterior reversible encephalopathy syndrome followed an upper gastrointestinal hemorrhage.", + "The patient was managed with induced hypothermia.", + "Induced hypothermia was used for control of intracranial hypertension.", + "The patient received continuous veno-venous hemodiafiltration.", + "Continuous veno-venous hemodiafiltration was used for severe hyperammonemia." + ] + }, + { + "id": "multiclinsum_test_429_en.txt", + "fulltext": "The patient was a 42-year-old female, with one previous pregnancy, with a history of cesarean section seven years previously and resection of endometriosis of the cephalic scar (Pfannenstiel) two years previously at another service, for which a histopathological diagnosis of abdominal wall endometriosis was made.\nHer condition evolved with progressive expansion in the region previously resected, for eight months, leading to presence of a bulging mass in the right side of the anterior abdominal wall, with cyclical local pain. During the investigation period, the patient said that she did not have any genitourinary or gastrointestinal symptoms, or any presence of lymph nodes or systemic symptoms.\nPhysical examination revealed a solid mass of approximately 10 cm x 6 cm in the anterior wall of the abdomen bordering the pubis. It extended inferiorly to the umbilical scar and laterally to the upper border of the iliac crest. At the time of the physical examination, there was no lymph node swelling in the inguinal region.\nLaboratory tests and tumor marker investigations (CA 125, CA 19-9, CEA and alpha-fetoprotein) were requested and these were found to be within normal limits. Computed tomography (CT) of the abdomen and pelvis revealed a heterogeneous expansive formation that was predominantly hypoattenuating, with images suggestive of internal septation. It measured around 10.6 cm x 4.7 cm x 8.3 cm along the major transverse, anteroposterior and longitudinal axes, respectively, and was located in the anterior pelvic wall, with the largest axis to the right of the midline, involving the rectus abdominis muscle .\nThe patient underwent exploratory laparotomy by means of a Pfannenstiel incision, followed by block resection of the abdominal mass with margins to the peritoneum, along with lymphadenectomy of the external and inguinal iliac chains. The abdominal wall was reconstructed to reconstitute the defect caused by resection of the tumor, using a semi-absorbable tissue-separating screen composed of a polypropylene parietal face and a visceral face coated with carboxymethyl cellulose. This rectangular sodium hyaluronate mesh measured 20.3 cm x 30.5 cm (Sempramesh IP Composite Bard Davol Inc.).\nHistological analysis on the abdominal mass revealed infiltration by malignant epithelioid neoplasia into soft tissues, thus confirming the immunohistochemical profile of adenocarcinoma with clear cell components . The antigens investigated in the immunohistochemical evaluation are listed in . Lymphadenectomy showed metastatic involvement of an external iliac chain lymph node (1/8), and that other lymph nodes of the iliac and inguinal chains presented lymphoid hyperplasia (0/11).\nOur patient is in her second postoperative month, without having presented any clinical or surgical intercurrence to date. She is being followed up by the oncology sector and an adjuvant chemotherapy scheme has been indicated.", + "fulltext_subclaims": [ + "The patient was a 42-year-old female.", + "She had one previous pregnancy.", + "She had a history of cesarean section seven years previously.", + "She had resection of endometriosis of the cephalic scar (Pfannenstiel) two years previously at another service.", + "A histopathological diagnosis of abdominal wall endometriosis was made.", + "Her condition evolved with progressive expansion in the region previously resected for eight months.", + "A bulging mass was present in the right side of the anterior abdominal wall.", + "She had cyclical local pain.", + "She said she did not have any genitourinary or gastrointestinal symptoms.", + "She said she did not have any presence of lymph nodes or systemic symptoms.", + "Physical examination revealed a solid mass of approximately 10 cm x 6 cm in the anterior wall of the abdomen bordering the pubis.", + "The mass extended inferiorly to the umbilical scar.", + "The mass extended laterally to the upper border of the iliac crest.", + "There was no lymph node swelling in the inguinal region at the time of the physical examination.", + "Laboratory tests and tumor marker investigations (CA 125, CA 19-9, CEA and alpha-fetoprotein) were requested.", + "The tumor markers were found to be within normal limits.", + "Computed tomography (CT) of the abdomen and pelvis revealed a heterogeneous expansive formation that was predominantly hypoattenuating.", + "The CT showed images suggestive of internal septation.", + "The mass measured around 10.6 cm x 4.7 cm x 8.3 cm.", + "The mass was located in the anterior pelvic wall.", + "The largest axis of the mass was to the right of the midline.", + "The mass involved the rectus abdominis muscle.", + "The patient underwent exploratory laparotomy by means of a Pfannenstiel incision.", + "The patient underwent block resection of the abdominal mass with margins to the peritoneum.", + "Lymphadenectomy of the external and inguinal iliac chains was performed.", + "The abdominal wall was reconstructed using a semi-absorbable tissue-separating screen composed of a polypropylene parietal face and a visceral face coated with carboxymethyl cellulose.", + "The mesh used was a rectangular sodium hyaluronate mesh measuring 20.3 cm x 30.5 cm.", + "Histological analysis on the abdominal mass revealed infiltration by malignant epithelioid neoplasia into soft tissues.", + "The immunohistochemical profile of the mass was that of adenocarcinoma with clear cell components.", + "Lymphadenectomy showed metastatic involvement of an external iliac chain lymph node (1/8).", + "Other lymph nodes of the iliac and inguinal chains presented lymphoid hyperplasia (0/11).", + "The patient is in her second postoperative month.", + "She has not presented any clinical or surgical intercurrence to date.", + "She is being followed up by the oncology sector.", + "An adjuvant chemotherapy scheme has been indicated." + ], + "summary": "We report a case of a 42-year-old woman with a history of abdominal surgery (Pfannenstiel) to resect abdominal wall endometriosis. Physical examination revealed a solid mass of approximately 10 cm x 6 cm in the anterior wall of the abdomen. Computed tomography (CT) of the abdomen and pelvis showed a heterogeneous, predominantly hypoattenuating expansive formation measuring 10.6 cm x 4.7 cm x 8.3 cm. The patient underwent exploratory incisional laparotomy, block resection of the abdominal mass and lymphadenectomy of the external and inguinal iliac chains. The abdominal wall was reconstructed using a semi-absorbable tissue-separating screen to reconstitute the defect caused by resection of the tumor. Histological evaluation revealed infiltration by malignant epithelioid neoplasia, thus confirming the immunohistochemical profile of adenocarcinoma with clear cell components. Lymphadenectomy showed metastatic involvement of an external iliac chain lymph node.", + "summary_subclaims": [ + "The patient is a 42-year-old woman.", + "The patient had a history of abdominal surgery (Pfannenstiel).", + "The surgery was to resect abdominal wall endometriosis.", + "Physical examination revealed a solid mass of approximately 10 cm x 6 cm in the anterior wall of the abdomen.", + "Computed tomography (CT) of the abdomen and pelvis showed a heterogeneous, predominantly hypoattenuating expansive formation.", + "The formation measured 10.6 cm x 4.7 cm x 8.3 cm.", + "The patient underwent exploratory incisional laparotomy.", + "The patient underwent block resection of the abdominal mass.", + "The patient underwent lymphadenectomy of the external and inguinal iliac chains.", + "The abdominal wall was reconstructed using a semi-absorbable tissue-separating screen.", + "Histological evaluation revealed infiltration by malignant epithelioid neoplasia.", + "The immunohistochemical profile confirmed adenocarcinoma with clear cell components.", + "Lymphadenectomy showed metastatic involvement of an external iliac chain lymph node." + ] + }, + { + "id": "multiclinsum_test_2972_en.txt", + "fulltext": "A 10-year-old Saudi Middle Eastern girl presented to King Abdulaziz University Faculty of Dentistry, Jeddah, Saudi Arabia, complaining of “malpositioned frontal teeth.” The patient’s medical history was insignificant. She had no known allergies or any possible syndrome. Her dental history was significant for multiple restorations. Her family history was insignificant. Her parents reported that their 10-year-old daughter did not pronounce the letters D, T, and Th correctly until the age of 7, and she had not received any previous medical intervention. Extraoral examination showed incompetent lips. Intraoral examination was within normal limits but revealed two lingual frenula with no limitation of tongue function . The patient faced no challenges. No further management regarding the lingual frenula was required. Her family members were also examined for double lingual frenula as part of the comprehensive assessment process. The patient’s father had a double lingual frenula, and two of her three siblings had no lingual frenulum. None of the family members had any syndromes. A written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images.", + "fulltext_subclaims": [ + "A 10-year-old Saudi Middle Eastern girl presented to King Abdulaziz University Faculty of Dentistry, Jeddah, Saudi Arabia.", + "The patient complained of 'malpositioned frontal teeth.'", + "The patient’s medical history was insignificant.", + "She had no known allergies or any possible syndrome.", + "Her dental history was significant for multiple restorations.", + "Her family history was insignificant.", + "Her parents reported that their 10-year-old daughter did not pronounce the letters D, T, and Th correctly until the age of 7.", + "She had not received any previous medical intervention.", + "Extraoral examination showed incompetent lips.", + "Intraoral examination was within normal limits.", + "The intraoral examination revealed two lingual frenula.", + "The patient faced no challenges.", + "No further management regarding the lingual frenula was required.", + "Her family members were also examined for double lingual frenula as part of the comprehensive assessment process.", + "The patient’s father had a double lingual frenula.", + "Two of her three siblings had no lingual frenulum.", + "None of the family members had any syndromes.", + "A written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images." + ], + "summary": "A 10-year-old healthy Saudi girl came to our dental clinic complaining of \"malpositioned frontal teeth.\" Upon intraoral examination, two lingual frenula were found connecting the tongue with the floor of the mouth. Intraoral examination revealed no other abnormalities.", + "summary_subclaims": [ + "The patient is a 10-year-old healthy Saudi girl.", + "The patient came to the dental clinic complaining of 'malpositioned frontal teeth.'", + "Intraoral examination found two lingual frenula connecting the tongue with the floor of the mouth.", + "Intraoral examination revealed no other abnormalities." + ] + }, + { + "id": "multiclinsum_test_1125_en.txt", + "fulltext": "A 43-year-old woman visited the Department of Obstetrics and Gynecology because of fluid collection in her cul-de-sac that was incidentally found 6 months ago at a routine health check. She did not complain of any other symptom except for dull abdominal discomfort. During physical examination, a mass-like hardness could be palpated on the level above the umbilicus. Routine blood analysis was within normal limits.\nA computed tomography (CT) scan of the abdomen was performed, and it revealed a 9.0-cm enhancing mass in the omentum at the right upper quadrant of the abdomen. The mass showed a relatively demarcated margin and some minute cystic changes. The radiologist thought the mass was a gastrointestinal stromal tumor (GIST) or neurogenic tumor. Additionally, there was a noted 2.5-cm corpus luteal cyst in the left ovary but otherwise there were no other abnormalities in the abdominal and pelvic cavities. The clinicians decided to excise the mass due to its huge size and to accurately diagnose the tumor.\nIn the operative field, the mass was located around the distal antrum along the greater curvature of the stomach but was easily separated from the stomach wall itself. On the other hand, it was densely adhered to the omentum and mesocolon. The tumor was far away from the reproductive organs, such as the uterus and both ovaries, and urinary structures.\nOn gross pathological examination, the excised mass measured 9.5 × 8.0 × 7.5 cm. On sectioning, the cut surface of the mass was yellow pink and showed a solid lobular portion and focal small cystic areas. Its margin was well demarcated from the attached omental fat tissue .\nMicroscopically, the tumor showed two histologic components. The first cellular part consisted of well-defined nests of round or polygonal epithelial cells and numerous ill-defined lobular islands of epithelial cells with short spindled features . The nests of polygonal epithelial cells were intimately related to the surrounding epithelial cells with short spindled features . In the well-defined nests, the epithelial cells had elongated nuclei and rather pale eosinophilic cytoplasm. Characteristically, many cells showed a longitudinal groove in the nuclei and frequent perinuclear haloes . Their cytologic features were similar to that of normal urothelial cells. Some nests showed cystic changes of varying degrees . The epithelial cells with short spindled features were arranged into ill-defined lobules or scattered singly and showed poorly defined cytoplasmic outlines . In the nuclei, the nuclear chromatin was fine and the nucleoli were small or inconspicuous. The cells also displayed occasional nuclear grooves. Neither cytologic atypia nor mitotic activity was noted in both types of cells. The second component was densely hyalinized fibrous stroma occupying areasbetween the cellular parts. The microscopic features of this tumor as a whole closely resembled an ordinary ovarian Brenner tumor.\nWe performed immunohistochemistry on a Leica Bond-Max automatic slide immunostainer (Leica Biosystems Melbourne Pty., Ltd. VIC, Australia) using a standard protocol. The list of antibodies used is as follows: calretinin (Novocastra, diluted 1:200), CK7 (NeoMarkers, 1:400), CK20 (Novocastra, 1: 100), pancytokeratin (Novocastra, 1:100), CD10 (Novocastra, 1:150), CD34 (DAKO, 1:400), DOG-1 (Cell Marque, 1:250), c-KIT (DAKO, 1:300), p63 (Novocastra, 1:100), PAX-8 (Cell Marque, 1:200), SMA (DAKO, 1:400), vimentin (Zymed, 1:200), WT-1 (DAKO, 1:100), uroplakin-III (Cell Marque, 1:50), and GATA-3 (Cell Marque, 1:100).\nThe cellular parts, including the urothelium-like cells and spindled epithelial cells were positive for pancytokeratin, p63, and WT-1 but negative for CD34, CD10, CK20, calretinin, c-KIT, DOG-1, and PAX-8. The urothelium-like cells were positive for CK7 but the spindled epithelial cells were negative. The cytoplasm of the urothelium-like cells was weakly to moderately positive for uroplakin-III, and their nuclei were diffusely strongly positive for GATA-3. The immunoprofiles of the urothelial-type cell nests in this tumor were the same as those of ovarian Brenner tumors. The spindled epithelial cells were negative for both uroplakin-III and GATA-3. The stromal cells only showed focal positivity for SMA .\nUsing a representative paraffin block of the tumor, we performed mutation analyses for exons 9, 11, 13, and 17 of the c-KIT gene by polymerase chain reaction (GeneAmp PCR System 2700, USA) using a direct sequencing method (Applied Biosystems 3500 Genetic Analyzer, USA). The results of the c-KIT gene mutation analyses were negative.\nAfter surgery, the patient had recovered well and showed no recurrence during the 17-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 43-year-old woman.", + "She had fluid collection in her cul-de-sac found 6 months ago.", + "She did not complain of any other symptom except for dull abdominal discomfort.", + "A mass-like hardness could be palpated on the level above the umbilicus.", + "Routine blood analysis was within normal limits.", + "A CT scan revealed a 9.0-cm enhancing mass in the omentum at the right upper quadrant.", + "The mass showed a relatively demarcated margin and some minute cystic changes.", + "The radiologist thought the mass was a gastrointestinal stromal tumor (GIST) or neurogenic tumor.", + "There was a noted 2.5-cm corpus luteal cyst in the left ovary.", + "The clinicians decided to excise the mass due to its huge size and to accurately diagnose the tumor.", + "In the operative field, the mass was located around the distal antrum along the greater curvature of the stomach.", + "The tumor was easily separated from the stomach wall itself.", + "The tumor was densely adhered to the omentum and mesocolon.", + "The tumor was far away from the reproductive organs, such as the uterus and both ovaries.", + "The tumor was far away from urinary structures.", + "On gross pathological examination, the excised mass measured 9.5 × 8.0 × 7.5 cm.", + "The cut surface of the mass was yellow pink and showed a solid lobular portion and focal small cystic areas.", + "The margin was well demarcated from the attached omental fat tissue.", + "The tumor showed two histologic components.", + "The first cellular part consisted of well-defined nests of round or polygonal epithelial cells.", + "The nests of polygonal epithelial cells were intimately related to the surrounding epithelial cells with short spindled features.", + "The epithelial cells had elongated nuclei and rather pale eosinophilic cytoplasm.", + "Many cells showed a longitudinal groove in the nuclei and frequent perinuclear haloes.", + "The cells displayed occasional nuclear grooves.", + "Neither cytologic atypia nor mitotic activity was noted in both types of cells.", + "The second component was densely hyalinized fibrous stroma.", + "The microscopic features of this tumor as a whole closely resembled an ordinary ovarian Brenner tumor.", + "Immunohistochemistry was performed using a Leica Bond-Max automatic slide immunostainer.", + "The cellular parts were positive for pancytokeratin, p63, and WT-1.", + "The cellular parts were negative for CD34, CD10, CK20, calretinin, c-KIT, DOG-1, and PAX-8.", + "The urothelium-like cells were positive for CK7.", + "The spindled epithelial cells were negative for CK7.", + "The urothelium-like cells were weakly to moderately positive for uroplakin-III.", + "The nuclei of the urothelium-like cells were diffusely strongly positive for GATA-3.", + "The spindled epithelial cells were negative for both uroplakin-III and GATA-3.", + "The stromal cells only showed focal positivity for SMA.", + "Mutation analyses for exons 9, 11, 13, and 17 of the c-KIT gene were performed.", + "The results of the c-KIT gene mutation analyses were negative.", + "After surgery, the patient had recovered well.", + "The patient showed no recurrence during the 17-month follow-up." + ], + "summary": "A 43-year-old woman presented with a palpable abdominal mass. Computed tomography (CT) scan revealed a 9.0-cm solid mass in the omentum. The tumor was not associated with pelvic structures, including the ovaries. It was excised under the clinical impression of an extragastrointestinal stromal tumor or neurogenic tumor. Grossly, the mass was a well-circumscribed solid tumor, with yellow-tan cut surface and minute cystic spaces. Microscopically, the tumor showed well-defined epithelial nests with variable cystic changes embedded in an abundant fibrous stroma. The cells within the nests were reminiscent of benign urothelial cells in that they had oval, frequently grooved nuclei. The epithelial cells focally showed a gradual transition into the surrounding stromal cells with short spindled features. The urothelium-like cells were positive for pancytokeratin, WT-1, p63, CK7, uroplakin-III, and GATA-3 but were negative for CD34, CD10, CK20, c-KIT, DOG-1, PAX-8, and calretinin. Morphological and immunohistochemical features of the tumor were the same as an ovarian Brenner tumor, and so it was diagnosed as an extraovarian Brenner tumor.", + "summary_subclaims": [ + "The patient was a 43-year-old woman.", + "The patient had a palpable abdominal mass.", + "Computed tomography (CT) scan revealed a 9.0-cm solid mass in the omentum.", + "The tumor was not associated with pelvic structures, including the ovaries.", + "The tumor was excised under the clinical impression of an extragastrointestinal stromal tumor or neurogenic tumor.", + "Grossly, the mass was a well-circumscribed solid tumor.", + "The cut surface of the mass was yellow-tan with minute cystic spaces.", + "Microscopically, the tumor showed well-defined epithelial nests with variable cystic changes embedded in an abundant fibrous stroma.", + "The cells within the nests had oval, frequently grooved nuclei.", + "The epithelial cells focally showed a gradual transition into the surrounding stromal cells with short spindled features.", + "The urothelium-like cells were positive for pancytokeratin.", + "The urothelium-like cells were positive for WT-1.", + "The urothelium-like cells were positive for p63.", + "The urothelium-like cells were positive for CK7.", + "The urothelium-like cells were positive for uroplakin-III.", + "The urothelium-like cells were positive for GATA-3.", + "The urothelium-like cells were negative for CD34.", + "The urothelium-like cells were negative for CD10.", + "The urothelium-like cells were negative for CK20.", + "The urothelium-like cells were negative for c-KIT.", + "The urothelium-like cells were negative for DOG-1.", + "The urothelium-like cells were negative for PAX-8.", + "The urothelium-like cells were negative for calretinin.", + "Morphological and immunohistochemical features of the tumor were the same as an ovarian Brenner tumor.", + "The tumor was diagnosed as an extraovarian Brenner tumor." + ] + }, + { + "id": "multiclinsum_test_1966_en.txt", + "fulltext": "A 74-year-old Japanese woman gradually developed general malaise and loss of appetite. In addition, arthralgia and pitting edema in her feet appeared. Her laboratory findings revealed an elevated white blood cell (WBC) count and C-reactive protein (CRP). She was admitted to our hospital for further examination. She had an operation for endometrial cancer at the age of 72 and had no family history.\nOn admission, her blood pressure was 129/76 mmHg, heart rate was 101/minute, respiratory rate was 18/minute, and body temperature was 39.1 °C. A physical examination revealed pitting edema on the dorsum of her hands and feet. Her neurological examination was unremarkable. However, she had difficulty with squatting and walking because of arthralgia in her proximal lower limbs. Laboratory testing showed a WBC of 11700/μL, CRP of 6.7 mg/dL, erythrocyte sedimentation rate of 44 mm/hour, total protein of 5.8 g/dL, and albumin of 2.3 g/dL. Rheumatoid factor, anti Ro/SSA antibody, anti La/SSB antibody, anti Scleroderma 70 antibody, and anti cyclic citrullinated peptide antibody were negative. Serum interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) were markedly increased to 285 pg/mL (normal; <2 pg/mL) and 1820 pg/mL (normal; 262±228 pg/mL) , respectively. Her human leukocyte antigen (HLA) typing included B7. A chest X-ray revealed mild pleural effusion on the right side. Electrocardiography showed a complete right bundle branch block without ST-T change. Echocardiography revealed a slight pericardial effusion surrounding her entire heart.\nShe had a high fever, general malaise, and muscle weakness, and her laboratory tests revealed elevated inflammatory markers including WBC, CRP, and erythrocyte sedimentation rate. Because infectious disease was suspected, tazobactam-piperacillin 13.5 mg/day was started. On day 2, atrial fibrillation appeared on the electrocardiography monitor. A chest X-ray showed that the pleural effusion had increased in both lungs. Furthermore, echocardiography demonstrated increased pericardial effusion around her heart. On day 3, she developed respiratory failure, and oxygen administration was started by nasal cannula at a dose of 3 L/minute. Enhanced chest-abdominal computed tomography (CT) showed marked bilateral pleural and pericardial effusions without neoplastic lesions . Analysis of the pleural effusion revealed exudate with an increased protein level and neutrophils, but cytological evaluation of the pleural effusion revealed no evidence of malignancy. Cultures of blood and pleural effusion were all negative. Our patient fulfilled the diagnostic criteria of RS3PE syndrome including: 1) pitting edema of the hands and feet; 2) sudden onset of polyarthritis; 3) onset at age 50 years or older; and 4) negative serology for rheumatoid factors . From day 6, she was treated with methylprednisolone administered intravenously at a dose of 1000 mg/day for 3 days. After steroid therapy, her fever rapidly improved, and blood tests revealed a decrease in CRP to 1.71 mg/dL. The pleural and pericardial effusions on chest CT decreased . When the pericardial effusion decreased, her atrial fibrillation disappeared. After steroid pulse therapy, oral prednisolone administration at a dose of 15 mg/day was started. Her respiratory failure immediately improved, and then she no longer required oxygen administration. A chest CT performed on day 38 revealed that the pleural and pericardial effusions had disappeared . On day 45, she was discharged. One year later, the prednisolone dosage was decreased to 8 mg/day, but the patient experienced no recurrence of symptoms. At the 1-year examination, no malignancy was found. Serum IL-6 and VEGF were significantly decreased to 1.3 pg/mL and 562 pg/mL, respectively.", + "fulltext_subclaims": [ + "A 74-year-old Japanese woman gradually developed general malaise and loss of appetite.", + "Arthralgia and pitting edema in her feet appeared.", + "Her laboratory findings revealed an elevated white blood cell (WBC) count and C-reactive protein (CRP).", + "She was admitted to our hospital for further examination.", + "She had an operation for endometrial cancer at the age of 72.", + "On admission, her body temperature was 39.1 °C.", + "A physical examination revealed pitting edema on the dorsum of her hands and feet.", + "She had difficulty with squatting and walking because of arthralgia in her proximal lower limbs.", + "Laboratory testing showed a WBC of 11700/μL.", + "CRP was 6.7 mg/dL.", + "Erythrocyte sedimentation rate was 44 mm/hour.", + "Total protein was 5.8 g/dL.", + "Albumin was 2.3 g/dL.", + "Rheumatoid factor, anti Ro/SSA antibody, anti La/SSB antibody, anti Scleroderma 70 antibody, and anti cyclic citrullinated peptide antibody were negative.", + "Serum interleukin-6 (IL-6) was 285 pg/mL.", + "Serum vascular endothelial growth factor (VEGF) was 1820 pg/mL.", + "Her human leukocyte antigen (HLA) typing included B7.", + "A chest X-ray revealed mild pleural effusion on the right side.", + "Echocardiography revealed a slight pericardial effusion surrounding her entire heart.", + "She had a high fever, general malaise, and muscle weakness.", + "Her laboratory tests revealed elevated inflammatory markers including WBC, CRP, and erythrocyte sedimentation rate.", + "Tazobactam-piperacillin 13.5 mg/day was started.", + "On day 2, atrial fibrillation appeared on the electrocardiography monitor.", + "A chest X-ray showed that the pleural effusion had increased in both lungs.", + "Echocardiography demonstrated increased pericardial effusion around her heart.", + "On day 3, she developed respiratory failure.", + "Oxygen administration was started by nasal cannula at a dose of 3 L/minute.", + "Enhanced chest-abdominal computed tomography (CT) showed marked bilateral pleural and pericardial effusions without neoplastic lesions.", + "Analysis of the pleural effusion revealed exudate with an increased protein level and neutrophils.", + "Cytological evaluation of the pleural effusion revealed no evidence of malignancy.", + "Cultures of blood and pleural effusion were all negative.", + "Our patient fulfilled the diagnostic criteria of RS3PE syndrome.", + "She was treated with methylprednisolone administered intravenously at a dose of 1000 mg/day for 3 days.", + "After steroid therapy, her fever rapidly improved.", + "Blood tests revealed a decrease in CRP to 1.71 mg/dL.", + "The pleural and pericardial effusions on chest CT decreased.", + "When the pericardial effusion decreased, her atrial fibrillation disappeared.", + "After steroid pulse therapy, oral prednisolone administration at a dose of 15 mg/day was started.", + "Her respiratory failure immediately improved.", + "A chest CT performed on day 38 revealed that the pleural and pericardial effusions had disappeared.", + "On day 45, she was discharged.", + "One year later, the prednisolone dosage was decreased to 8 mg/day.", + "The patient experienced no recurrence of symptoms.", + "At the 1-year examination, no malignancy was found.", + "Serum IL-6 was significantly decreased to 1.3 pg/mL.", + "Serum VEGF was significantly decreased to 562 pg/mL." + ], + "summary": "A 74-year-old Japanese woman presented to our hospital with arthralgia and pitting edema in her feet. She had pain in multiple joints, peripheral edema, and a markedly elevated erythrocyte sedimentation rate. Enhanced computed tomography and laboratory data showed no evidence of malignancy. These findings suggested that she had idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome. She also developed respiratory distress because of bilateral pleural and pericardial effusions. Laboratory data showed that serum vascular endothelial growth factor and interleukin-6 were significantly elevated. After administration of steroids, her pleural and pericardial effusions decreased and finally disappeared. Furthermore, vascular endothelial growth factor and interleukin-6 decreased when the pleural and pericardial effusions disappeared.", + "summary_subclaims": [ + "The patient was a 74-year-old Japanese woman.", + "She presented with arthralgia and pitting edema in her feet.", + "She had pain in multiple joints.", + "She had peripheral edema.", + "Her erythrocyte sedimentation rate was markedly elevated.", + "Enhanced computed tomography and laboratory data showed no evidence of malignancy.", + "These findings suggested idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome.", + "She developed respiratory distress because of bilateral pleural and pericardial effusions.", + "Serum vascular endothelial growth factor was significantly elevated.", + "Serum interleukin-6 was significantly elevated.", + "After administration of steroids, her pleural and pericardial effusions decreased and finally disappeared.", + "Vascular endothelial growth factor and interleukin-6 decreased when the pleural and pericardial effusions disappeared." + ] + }, + { + "id": "multiclinsum_test_903_en.txt", + "fulltext": "The disease manifested in a healthy 53 years old female patient 7 weeks prior to the initial visit to our center with sudden onset of blurred vision, dizziness, disturbed gait and coordination impairment. Before the manifestation of symptoms patient was healthy, no prior dementia cases in patient’s family history were recorded. Two weeks after initial symptoms presentation patient was hospitalized in the Department of Neurology of Regional Hospital. Neither ophthalmologic examination nor blood test revealed any significant changes. Brain computed tomography (CT) and MRI were evaluated as normal. Although after retrospective reevaluation of MRI, slight increase in the occipital DW signal was found . EEG was performed on the 6th week since initial disease presentation did not show any specific changes. Initially, the patient was diagnosed with primary hypertension (blood pressure was 150/70 mmHg): Spironolactone 25 mg per day for arterial hypertension and Clonazepam 0,5 mg once a day for insomnia, Betahistine 3 mg three times a day were prescribed. On the sixth week after initial symptoms due to complaints of dizziness, impaired memory, insomnia, emotional lability, the possible causes were differentiated among cerebrovascular and somatoform/conversion disorder. As the symptoms progressed significantly, on the 7th week after the onset of symptoms, the patient was referred to the University Hospital. Clinical course of the disease and the major diagnostic tests are presented in Fig. .\nDuring the hospital admission the patient complained of weakness, difficulties standing up and walking due to dizziness and visual impairment as well as difficulties concentrating during the interview. A neurological evaluation revealed vertical gaze palsy, extrapyramidal type increased right body side muscle tonus, involuntary stereotypical movements (purposeless raising and lowering of the left hand), weaker reflexes on the left side and ataxic gait. Arterial blood pressure was 160/90 mmHg. Ophthalmologic examination revealed severely impaired vision, a disability to distinguish between light and darkness, without any congestive changes in the retina. The evaluation of mental state revealed typical symptoms of organic brain disease: disorientation in time, slower thought processing, concentration difficulties and disturbed short-term memory. Mini-Mental State Examination score 20/30 revealed dementia with moderate cognitive decline, two in date and two points in place orientation were missed, three in recall, two in attention and calculation, one in repetition. Due to episodic anxiety, agitation and fearful gaze, visual hallucinations were suspected. Physical examination of other systems did not reveal any significant abnormalities.\nDuring the next two weeks blood tests were carried out to rule out infectious, endocrine and rheumatologic diseases, metabolic conditions and secondary autoimmune central nervous system vasculitis since they are common causes of dementia; genetic testing, urine analysis and a liver biopsy were performed in search for Wilson’s disease, but all the tests were negative. Standard examination of CSF did not reveal significant deviations from the normal range. Despite antihypertensive treatment, arterial blood pressure was ranging between 160/100 and 140/85 mmHg.\nEEGs performed on the 10th and 14th weeks after the onset of symptoms showed non-specific diffuse slowing activity with rhythmic delta activity in frontal brain regions (FIRDA), predominantly in the left side. Only at the 18th week EEG showed periodic (repeated every 1 s) sharp wave complexes (PSWC) in frontal regions .\nThe MRI, done on the 9th week showed in T2W increased signal intensity (SI) zones in cortical gray and subcortical white matter, especially on the right side without restriction in DWI sequence, in the parietal-occipital area supplied by the posterior cerebral artery, leading to the conclusion of posterior reversible encephalopathy syndrome (PRES). The typical imaging finding is vasogenic oedema in the subcortical white matter of the parietal and occipital lobes . As an experience with PRES grows, atypical presentations of PRES are being increasingly described: the cases with atypical vasogenic oedema patterns of distribution, such as frontal lobe, cerebellum, basal ganglia or brain stem involvement [–]. This non-specific radiological pattern in our case also raised a new diagnostic challenge. Normalization of blood pressure due to antihypertensive treatment and other symptomatic treatment did not improve neurologic symptoms. During the period of the next two weeks all possible causes (vascular, ictal, infectious) of PRES were ruled out . A diagnosis of CJD was suspected the first time.\nIn MRI, repeated after four weeks, on the 13th week symmetrical lesions in the basal ganglia (head of nucleus caudatus, putamen) were found. The previous lesions in the cortical/subcortical area were absorbed. The lesions found in the basal ganglia led us to suspect CJD or extrapontine myelinolysis [, ].\nWithin 14th week of the disease onset and the symptomatic treatment, the patient’s condition significantly deteriorated. Severe psychomotor retardation with hyper tonus of neck and arms flexor muscles, jerky myoclonic movements, repeated episodes of agitation and severe insomnia were observed. Condition progressed to akinetic mutism with severe cognitive impairment. The blood pressure reversed into hypotensive state. There was no possibility in Lithuania to test the 14–3–3 protein, most widely used CSF biomarker for CJD and one of the WHO criteria, for probable CJD. Taken into account a rapidly progressive dementia, clinical manifestation of myoclonus, visual changes, ataxia, muscle hyper tonus, akinetic mutism, symmetrical MRI findings of basal ganglia, on the 14th week of the disease the decision to take brain biopsy was made.\nThe brain tissue biopsy from occipital brain lobe and head of caudate nucleus was performed. Histological evaluation was performed in the Division of Neuropathology of the National Hospital for Neurology and Neurosurgery, Queen Square, London: the abnormal prion protein deposits (detected with antibodies ICSM35, KG9 and 12 F10) were seen in all the grey matter areas . No specific features in small biopsy samples were found to suggest iatrogenic or inherited forms of prion disease. Patient had not received any past treatment with human cadaver derived growth hormone, undergone neurosurgery with human cadaver derived dural graft or scleral transplant, patient had not received blood transfusion, which suggests a possible sporadic case of CJD. The neuropil in the grey matter of caudate nucleus showed mild but widespread micro-vacuolar degeneration. In the neuropil of occipital cortex mild micro-vacuolar degeneration is patchy. Immunostaining for the abnormal prion protein revealed diffuse strong synaptic labelling in all the grey matter regions. In the white matter there are freaquent granular deposits but no convincing filamentous labelling. Histopathological and immuno-histochemical findings of prion protein (scrapie) (PrPSc) and summarizing all the data, we confirmed prion disease, compatible with sCJD. The patient eventually died 13 months after disease onset. Autopsy was not carried out.", + "fulltext_subclaims": [ + "The disease manifested in a healthy 53 years old female patient 7 weeks prior to the initial visit to our center.", + "The patient experienced sudden onset of blurred vision, dizziness, disturbed gait and coordination impairment.", + "Before the manifestation of symptoms, the patient was healthy.", + "No prior dementia cases in patient’s family history were recorded.", + "Two weeks after initial symptoms presentation, the patient was hospitalized in the Department of Neurology of Regional Hospital.", + "Neither ophthalmologic examination nor blood test revealed any significant changes.", + "Brain computed tomography (CT) and MRI were evaluated as normal.", + "After retrospective reevaluation of MRI, slight increase in the occipital DW signal was found.", + "EEG was performed on the 6th week since initial disease presentation and did not show any specific changes.", + "Initially, the patient was diagnosed with primary hypertension.", + "Blood pressure was 150/70 mmHg.", + "Spironolactone 25 mg per day was prescribed for arterial hypertension.", + "Clonazepam 0,5 mg once a day was prescribed for insomnia.", + "Betahistine 3 mg three times a day was prescribed.", + "On the sixth week after initial symptoms, the patient complained of dizziness, impaired memory, insomnia, emotional lability.", + "The possible causes were differentiated among cerebrovascular and somatoform/conversion disorder.", + "On the 7th week after the onset of symptoms, the patient was referred to the University Hospital.", + "During the hospital admission, the patient complained of weakness, difficulties standing up and walking due to dizziness and visual impairment.", + "Neurological evaluation revealed vertical gaze palsy.", + "Extrapyramidal type increased right body side muscle tonus was found.", + "Involuntary stereotypical movements (purposeless raising and lowering of the left hand) were observed.", + "Weaker reflexes on the left side were found.", + "Ataxic gait was observed.", + "Arterial blood pressure was 160/90 mmHg.", + "Ophthalmologic examination revealed severely impaired vision.", + "The patient could not distinguish between light and darkness.", + "No congestive changes in the retina were found.", + "Evaluation of mental state revealed typical symptoms of organic brain disease.", + "Mini-Mental State Examination score 20/30 revealed dementia with moderate cognitive decline.", + "Two in date and two points in place orientation were missed.", + "Three in recall, two in attention and calculation, one in repetition.", + "Due to episodic anxiety, agitation and fearful gaze, visual hallucinations were suspected.", + "Physical examination of other systems did not reveal any significant abnormalities.", + "Blood tests were carried out to rule out infectious, endocrine and rheumatologic diseases, metabolic conditions and secondary autoimmune central nervous system vasculitis.", + "Genetic testing, urine analysis and a liver biopsy were performed in search for Wilson’s disease.", + "All the tests were negative.", + "Standard examination of CSF did not reveal significant deviations from the normal range.", + "Despite antihypertensive treatment, arterial blood pressure was ranging between 160/100 and 140/85 mmHg.", + "EEGs performed on the 10th and 14th weeks after the onset of symptoms showed non-specific diffuse slowing activity with rhythmic delta activity in frontal brain regions (FIRDA), predominantly in the left side.", + "Only at the 18th week EEG showed periodic (repeated every 1 s) sharp wave complexes (PSWC) in frontal regions.", + "The MRI, done on the 9th week showed in T2W increased signal intensity (SI) zones in cortical gray and subcortical white matter, especially on the right side without restriction in DWI sequence.", + "The lesions were in the parietal-occipital area supplied by the posterior cerebral artery.", + "This led to the conclusion of posterior reversible encephalopathy syndrome (PRES).", + "The typical imaging finding is vasogenic oedema in the subcortical white matter of the parietal and occipital lobes.", + "Atypical presentations of PRES are being increasingly described.", + "The non-specific radiological pattern in our case also raised a new diagnostic challenge.", + "Normalization of blood pressure due to antihypertensive treatment and other symptomatic treatment did not improve neurologic symptoms.", + "During the period of the next two weeks, all possible causes (vascular, ictal, infectious) of PRES were ruled out.", + "A diagnosis of CJD was suspected the first time.", + "In MRI, repeated after four weeks, on the 13th week symmetrical lesions in the basal ganglia (head of nucleus caudatus, putamen) were found.", + "The previous lesions in the cortical/subcortical area were absorbed.", + "The lesions found in the basal ganglia led us to suspect CJD or extrapontine myelinolysis.", + "Within 14th week of the disease onset and the symptomatic treatment, the patient’s condition significantly deteriorated.", + "Severe psychomotor retardation with hyper tonus of neck and arms flexor muscles was observed.", + "Jerky myoclonic movements were observed.", + "Repeated episodes of agitation and severe insomnia were observed.", + "Condition progressed to akinetic mutism with severe cognitive impairment.", + "Blood pressure reversed into hypotensive state.", + "There was no possibility in Lithuania to test the 14–3–3 protein, most widely used CSF biomarker for CJD.", + "Taken into account a rapidly progressive dementia, clinical manifestation of myoclonus, visual changes, ataxia, muscle hyper tonus, akinetic mutism, symmetrical MRI findings of basal ganglia, on the 14th week of the disease the decision to take brain biopsy was made.", + "The brain tissue biopsy from occipital brain lobe and head of caudate nucleus was performed.", + "Histological evaluation was performed in the Division of Neuropathology of the National Hospital for Neurology and Neurosurgery, Queen Square, London.", + "Abnormal prion protein deposits (detected with antibodies ICSM35, KG9 and 12 F10) were seen in all the grey matter areas.", + "No specific features in small biopsy samples were found to suggest iatrogenic or inherited forms of prion disease.", + "The patient had not received any past treatment with human cadaver derived growth hormone.", + "The patient had not undergone neurosurgery with human cadaver derived dural graft or scleral transplant.", + "The patient had not received blood transfusion.", + "This suggests a possible sporadic case of CJD.", + "The neuropil in the grey matter of caudate nucleus showed mild but widespread micro-vacuolar degeneration.", + "In the neuropil of occipital cortex mild micro-vacuolar degeneration is patchy.", + "Immunostaining for the abnormal prion protein revealed diffuse strong synaptic labelling in all the grey matter regions.", + "In the white matter there are frequent granular deposits but no convincing filamentous labelling.", + "Histopathological and immuno-histochemical findings of prion protein (scrapie) (PrPSc) and summarizing all the data, we confirmed prion disease, compatible with sCJD.", + "The patient eventually died 13 months after disease onset.", + "Autopsy was not carried out." + ], + "summary": "We present a case of 53-year-old woman with a history of a rapidly progressive dementia with symptoms of visual impairment, increased extrapyramidal type muscle tonus, stereotypical movements and ataxic gait resulting in the patient's death after13 months. The clinical symptoms deteriorated progressively to myoclonus and akinetic mutism already on the 14th week. The series of diagnostic examinations were done to exclude the possible causes of dementia. Initial MRI evaluation as posterior reversible encephalopathy syndrome (PRES) on the 9th week after the onset of symptoms created us a diagnostic conundrum. Subsequent MRI findings of symmetrical lesions in the basal ganglia (nucleus caudatus, putamen) on the 13th week and EEG with periodic sharp wave complexes (PSWC) in frontal regions on the 18th week allowed us to diagnose the probable sCJD. The histopathological findings after brain biopsy on the 14th week demonstrated the presence of the abnormal prion protein deposits in the grey matter by immunohistochemistry with ICSM35, KG9 and 12 F10 antibodies and confirmed the diagnosis of sCJD.", + "summary_subclaims": [ + "The patient was a 53-year-old woman.", + "The patient had a history of rapidly progressive dementia.", + "The patient had symptoms of visual impairment.", + "The patient had increased extrapyramidal type muscle tonus.", + "The patient had stereotypical movements.", + "The patient had ataxic gait.", + "The patient died after 13 months.", + "The clinical symptoms deteriorated progressively to myoclonus.", + "The clinical symptoms deteriorated progressively to akinetic mutism.", + "The deterioration to myoclonus and akinetic mutism occurred on the 14th week.", + "Diagnostic examinations were done to exclude possible causes of dementia.", + "Initial MRI evaluation suggested posterior reversible encephalopathy syndrome (PRES).", + "The MRI evaluation suggesting PRES occurred on the 9th week after symptom onset.", + "Subsequent MRI findings showed symmetrical lesions in the basal ganglia.", + "The MRI findings of symmetrical lesions in the basal ganglia occurred on the 13th week.", + "The MRI findings included lesions in the nucleus caudatus.", + "The MRI findings included lesions in the putamen.", + "EEG showed periodic sharp wave complexes (PSWC) in frontal regions.", + "The EEG findings occurred on the 18th week.", + "The findings allowed the diagnosis of probable sCJD.", + "A brain biopsy was performed on the 14th week.", + "Histopathological findings demonstrated abnormal prion protein deposits in the grey matter.", + "Immunohistochemistry with ICSM35, KG9, and 12 F10 antibodies was used.", + "The histopathological findings confirmed the diagnosis of sCJD." + ] + }, + { + "id": "multiclinsum_test_1238_en.txt", + "fulltext": "Our case was a 14-year-old right-handed boy who complained of pain in his right middle finger. The finger was injured by a baseball impact, and the treating hospital performed splint fixation after diagnosing a fracture of the right middle finger. The patient failed to follow up his treatment on his own volition. However, pain in the right middle finger continued and the range of motion became restricted. He consulted our institution 5 months after injury.\nAt first consultation, there was swelling in the PIP joint of the right middle finger and displacement of that finger to the ulnar side at extension position . The range of motion of the PIP joint was limited between extension 0° and flexion 60°.\nX-ray images of posterior and anterior views showed bony defect in the articular surface of the PIP joint in the middle phalanx and displacement of the finger to the ulnar side. X-ray image of the lateral view showed depressed articular surface of the PIP joint . CT images showed a bony defect sized 5 × 6.5 × 2 mm in the articular surface of the PIP joint in the middle phalanx . From these imaging findings, we diagnosed the case as malunited intra-articular fracture of the PIP joint and decided to conduct surgical treatment. First, an incision was made by palmar approach and the PIP joint was exposed. A cartilage defect approximately 5 mm in diameter was seen in the articular surface of the middle phalanx, and a cartilage defect of 1 × 2 mm in size was seen in the palmar side of the articular surface of the proximal phalanx . After creating the drilled recipient hole at the osteochondral lesion of the middle phalanx, a cylindrical osteochondral plug of 4.5 mm diameter harvested from the left knee was inserted and press-fitted to the hole. The osteochondral plug was harvested using the mosaicplasty autogenous osteochondral grafting system (Acufex, Smith and Nephew, Andover, MA, USA) from a non-weight-bearing site on the upper lateral femoral condyle. The osteochondral plug was obtained with an obliquely angled cartilage surface along the long axis to facilitate insertion in the recipient hole . The cartilage defect in the proximal phalanx was left untreated as the range of damage was minimal.\nPostoperative splint fixation was done only on the day of surgery, and mobilization exercise was started from the next day by changing the splint fixation to buddy taping. The buddy taping was continued up to 3 months after surgery. After removing the buddy taping, the patient gradually resumed sports activity.\nAs of 1 year after surgery, the patient has no pain, and the ROM of the PIP joint has improved showing extension and flexion to 0° and 90°, respectively. Although slight displacement to the ulnar side remains in the PIP joint, instability is not noted, . There are no adverse effects in the donor site of the left knee. The patient resumed his previous level of baseball activity. Final follow-up X-ray and CT images showed bone union with no dislocation of the implanted osteochondral plug. Although slight displacement of the finger to ulnar side remained, the ulnar displacement of the axis improved from preoperative 14° to postoperative 8°. Also, MR images showed a well-maintained joint space by the transplanted cartilage .", + "fulltext_subclaims": [ + "The patient was a 14-year-old right-handed boy.", + "The patient complained of pain in his right middle finger.", + "The finger was injured by a baseball impact.", + "The treating hospital performed splint fixation after diagnosing a fracture of the right middle finger.", + "The patient failed to follow up his treatment on his own volition.", + "Pain in the right middle finger continued.", + "The range of motion became restricted.", + "He consulted our institution 5 months after injury.", + "At first consultation, there was swelling in the PIP joint of the right middle finger.", + "There was displacement of the right middle finger to the ulnar side at extension position.", + "The range of motion of the PIP joint was limited between extension 0° and flexion 60°.", + "X-ray images showed bony defect in the articular surface of the PIP joint in the middle phalanx.", + "X-ray images showed displacement of the finger to the ulnar side.", + "CT images showed a bony defect sized 5 × 6.5 × 2 mm in the articular surface of the PIP joint in the middle phalanx.", + "We diagnosed the case as malunited intra-articular fracture of the PIP joint.", + "We decided to conduct surgical treatment.", + "An incision was made by palmar approach and the PIP joint was exposed.", + "A cartilage defect approximately 5 mm in diameter was seen in the articular surface of the middle phalanx.", + "A cartilage defect of 1 × 2 mm in size was seen in the palmar side of the articular surface of the proximal phalanx.", + "A cylindrical osteochondral plug of 4.5 mm diameter was inserted and press-fitted to the hole.", + "The osteochondral plug was harvested using the mosaicplasty autogenous osteochondral grafting system.", + "The osteochondral plug was obtained with an obliquely angled cartilage surface along the long axis.", + "The cartilage defect in the proximal phalanx was left untreated.", + "Postoperative splint fixation was done only on the day of surgery.", + "Mobilization exercise was started from the next day by changing the splint fixation to buddy taping.", + "The buddy taping was continued up to 3 months after surgery.", + "The patient gradually resumed sports activity after removing the buddy taping.", + "As of 1 year after surgery, the patient has no pain.", + "The ROM of the PIP joint has improved showing extension and flexion to 0° and 90°, respectively.", + "Slight displacement to the ulnar side remains in the PIP joint.", + "Instability is not noted.", + "There are no adverse effects in the donor site of the left knee.", + "The patient resumed his previous level of baseball activity.", + "Final follow-up X-ray and CT images showed bone union with no dislocation of the implanted osteochondral plug.", + "Although slight displacement of the finger to ulnar side remained, the ulnar displacement of the axis improved from preoperative 14° to postoperative 8°.", + "MR images showed a well-maintained joint space by the transplanted cartilage." + ], + "summary": "A 14-year-old boy was injured at the right middle finger by a baseball impact and underwent conservative treatment. At 5 months after the injury, he complained of continuing pain and restricted ROM. Plain X-ray and CT images showed a bony defect in the articular surface of the PIP joint of the right middle finger. He was diagnosed with malunited intra-articular fracture of the PIP joint and underwent surgical treatment. First, through a palmar incision, a columnar-shaped drill hole was made at the recipient site of osteochondral defect. Then a cylindrical osteochondral plug, 4.5 mm in diameter, harvested from the knee, was inserted into the recipient hole and press-fitted. One year after surgery, the patient has neither pain nor ROM limitation of the finger and the knee joint. MRI showed smooth articular surface of the PIP joint.", + "summary_subclaims": [ + "A 14-year-old boy was injured at the right middle finger by a baseball impact and underwent conservative treatment.", + "At 5 months after the injury, he complained of continuing pain and restricted ROM.", + "Plain X-ray and CT images showed a bony defect in the articular surface of the PIP joint of the right middle finger.", + "He was diagnosed with malunited intra-articular fracture of the PIP joint and underwent surgical treatment.", + "Through a palmar incision, a columnar-shaped drill hole was made at the recipient site of osteochondral defect.", + "A cylindrical osteochondral plug, 4.5 mm in diameter, harvested from the knee, was inserted into the recipient hole and press-fitted.", + "One year after surgery, the patient has neither pain nor ROM limitation of the finger and the knee joint.", + "MRI showed smooth articular surface of the PIP joint." + ] + }, + { + "id": "multiclinsum_test_2375_en.txt", + "fulltext": "A 9 days-old male neonates weighing 3.60 kg was referred by local hospital to our center (National Cardiac Center Harapan Kita Hospital/NCCHK) and was ventilated because of severe metabolic and respiratory acidosis, circulatory dynamics instability with history of respiratory distress, cyanosis, hyperbilirubinemia and severe infection that present since he was born on year 2011. The perinatal history was unremarkable and at a previous hospital she was born at 40 weeks of gestation by normal labour with a birth weight of 3.85 kg, oxygen saturation 90% and an APGAR score of 9/9. On the 6th day postpartum he presented with feeding difficulty, severe cyanosis and congestive heart failure and was referred to local hospital for further treathment, was ventilated at the emergency room with oxygen saturation 82%, and then transferred to us for possible surgical repair. Stable hemodynamic with oxygen saturation was 75%, while differential oxygen saturation was noted between the both upper and lower limbs (89%; 76% and 97%; 83%, respectively). No apparent cardiac murmur was detected. His chest X-ray showed mild cardiomegaly and congestion of the lungs, and pulmonary edema. Electrocardiogram showed normal rhythm, right axes deviation, and mild right ventricular hypertrophy.\nAdmitted to our pediatric cardiac intensive care unit (PCICU) with oxygen saturation between 40% and 70%. Two-dimensional Echocardiography revealed an IAA type A and APW type II with a restricted PDA, pulmonary hypertension but no ventricular septal defect (, ). A PGE1 infusion 10 nano was started to re-open the ductus arteriosus and diuretics were administered. During the following days the baby had severe infection and DIC with increased of leucocyte 28.387, pro-calcitonine 11, D-dimer 4.800. Also had experienced of several epileptic episodes, and a brain sonography showed arachnoiditis, brain edema and no intracranial bleeding. Because of the risk of infection, sepsis and taking into account the good general condition, operation was deferred.\nAfter improvement of the clinical condition, operation was performed on the 20th days of life. A one-stage surgical correction was performed through a median sternotomy under profound hypothermia (26 °C). Before the administration of heparin, the entire ascending aorta and the arch vessels, pulmonary trunk and both branch were mobilized. The external anatomy confirmed an IAA type A and a large APW type II, and this time the right pulmonary artery (RPA) was recognized to originate from the posterolateral part of the ascending aorta, as well as connection with common pulmonary artery. Aorta and pulmonary arteries (PA) were obvious and intact at their origin. The ascending aorta is then come to end by giving three branches including, brachiocephalic artery, left common carotid artery, and left subclavian artery. There was not evidence of descending aorta. Proximal part of PDA arose from PA trunk which is distally becoming into descending aorta with left pulmonary artery are origin from PA trunk also detected at the same time (, ).\nCardiopulmonary bypass (CPB) was established by the right hemicerebral perfusion and the bicaval drainage. The right hemicerebral perfusion was obtained via expanded 4-0 mm polytetrafluoroethylene (ePTFE) graft sewn to the right brachiocephalic artery. The aortic cross clamp was applied (one-third flow) and cardioplegia was infused. Aortic arch vessels were clamped at the origin of the brachiocephalic artery, the left common carotid artery, and left subclavian artery. Immediately there after, snaring of both pulmonary arteries precluded overflooding the lungs, and the pump flow was lowered to 10% to perfuse only the myocardium. Ductal tissue was ligated near its pulmonary origin and resected until normal aortic tissue appeared, then the ascending aorta was longitudinally incised. An extended end-to-side anastomosis of the descending aorta to the distal ascending aorta was performed with a continuous 7-0 polypropylene suture. After removal of the aortic cross-clamp and off the snares in the vessels, full flow bypass was resumed and the anastomosis was checked for bleeding and undue tension.\nThe aortic cross-clamp was reapplied proximal to the aortic cannula, cardioplegia was infused, and the AP window repair was started. The ascending aorta was transversely incised distal to the AP window. Inspection confirmed the location of the AP window which appeared to be very large 10 mm diameter, as well as aortic origin of the RPA. The left pulmonary artery (LPA) arose from the PA trunk in the normal fashion. The coronary arteries were normally positioned. Becaused of the excessive blood flow distally, the aortic cross clamp was removed and reapplied for right hemicerebral perfusion again (one-third flow). A 4-0 Gore-tex patch was used both to close the aortopulmonary window and separated the right pulmonary artery from aortic origin (B).\nAfter rewarming, CPB was easily weaned with moderate inotropic support. Total bypass time was 125 minutes, cross clamp time 71 minutes and one-third flow 66 minutes. Peritoneal dialysis was performed post operatively for 3 days and electively switch with lasix intermitten.\nThe postoperative recovery was uneventful. Slowly weaning from ventilation and extubated on 7th day post operatively with good clinical condition. No clinical signs of neurologic disturbances were observed and cardiopulmonary function as well as distal perfusion were very satisfactory. Early postoperative echocardiography using colour doppler demonstrated an excellent early surgical result with a minimal pressure gradient of 12 mmHg across the aortic reconstruction with good LV function, no AP window residual.\nCurrently on year 2021, the patient has grown up as a cheerful 9 year old child who is growing actively and has entered elementary school in grade 2. There are no abnormalities of the heart and lungs according to the patient's mother and always carries out routinely follow up with the pediatric cardiologist. However, there is still a cerebral palsy sequela which is currently being treated by a pediatric neurologist.", + "fulltext_subclaims": [ + "A 9 days-old male neonate weighing 3.60 kg was referred to the National Cardiac Center Harapan Kita Hospital.", + "The neonate was ventilated because of severe metabolic and respiratory acidosis.", + "The neonate had circulatory dynamics instability.", + "The neonate had a history of respiratory distress.", + "The neonate had cyanosis.", + "The neonate had hyperbilirubinemia.", + "The neonate had a severe infection.", + "The perinatal history was unremarkable.", + "The neonate was born at 40 weeks of gestation by normal labour.", + "The neonate's birth weight was 3.85 kg.", + "The neonate's oxygen saturation at birth was 90%.", + "The neonate's APGAR score was 9/9.", + "On the 6th day postpartum, the neonate presented with feeding difficulty.", + "On the 6th day postpartum, the neonate had severe cyanosis.", + "On the 6th day postpartum, the neonate had congestive heart failure.", + "The neonate was ventilated at the emergency room with oxygen saturation 82%.", + "The neonate was transferred to the center for possible surgical repair.", + "The neonate's oxygen saturation was 75%.", + "Differential oxygen saturation was noted between the upper and lower limbs.", + "No apparent cardiac murmur was detected.", + "The chest X-ray showed mild cardiomegaly.", + "The chest X-ray showed congestion of the lungs.", + "The chest X-ray showed pulmonary edema.", + "The electrocardiogram showed normal rhythm.", + "The electrocardiogram showed right axis deviation.", + "The electrocardiogram showed mild right ventricular hypertrophy.", + "The neonate was admitted to the pediatric cardiac intensive care unit.", + "The neonate's oxygen saturation was between 40% and 70%.", + "Two-dimensional echocardiography revealed an interrupted aortic arch type A.", + "Two-dimensional echocardiography revealed an aortopulmonary window type II.", + "Two-dimensional echocardiography revealed a restricted patent ductus arteriosus.", + "Two-dimensional echocardiography revealed pulmonary hypertension.", + "Two-dimensional echocardiography did not reveal a ventricular septal defect.", + "A PGE1 infusion 10 nano was started.", + "Diuretics were administered.", + "The baby had severe infection.", + "The baby had disseminated intravascular coagulation.", + "The baby had leucocyte count 28.387.", + "The baby had pro-calcitonine 11.", + "The baby had D-dimer 4.800.", + "The baby had several epileptic episodes.", + "Brain sonography showed arachnoiditis.", + "Brain sonography showed brain edema.", + "Brain sonography showed no intracranial bleeding.", + "Operation was deferred because of the risk of infection.", + "Operation was deferred because of sepsis.", + "Operation was deferred because of the good general condition.", + "Operation was performed on the 20th day of life.", + "A one-stage surgical correction was performed through a median sternotomy.", + "The surgery was performed under profound hypothermia (26 °C).", + "Before the administration of heparin, the entire ascending aorta and the arch vessels were mobilized.", + "Before the administration of heparin, the pulmonary trunk and both branch were mobilized.", + "The external anatomy confirmed an interrupted aortic arch type A.", + "The external anatomy confirmed a large aortopulmonary window type II.", + "The right pulmonary artery was recognized to originate from the posterolateral part of the ascending aorta.", + "The right pulmonary artery was recognized to have connection with the common pulmonary artery.", + "The ascending aorta gave three branches including the brachiocephalic artery.", + "The ascending aorta gave three branches including the left common carotid artery.", + "The ascending aorta gave three branches including the left subclavian artery.", + "There was no evidence of descending aorta.", + "The proximal part of the patent ductus arteriosus arose from the pulmonary artery trunk.", + "The distal part of the patent ductus arteriosus became the descending aorta.", + "The left pulmonary artery arose from the pulmonary artery trunk.", + "Cardiopulmonary bypass was established by right hemicerebral perfusion.", + "Cardiopulmonary bypass was established by bicaval drainage.", + "Right hemicerebral perfusion was obtained via an expanded 4-0 mm polytetrafluoroethylene graft.", + "The graft was sewn to the right brachiocephalic artery.", + "The aortic cross clamp was applied.", + "Cardioplegia was infused.", + "The aortic arch vessels were clamped at the origin of the brachiocephalic artery.", + "The aortic arch vessels were clamped at the origin of the left common carotid artery.", + "The aortic arch vessels were clamped at the origin of the left subclavian artery.", + "Snaring of both pulmonary arteries precluded overflooding the lungs.", + "The pump flow was lowered to 10%.", + "Ductal tissue was ligated near its pulmonary origin.", + "Ductal tissue was resected until normal aortic tissue appeared.", + "The ascending aorta was longitudinally incised.", + "An extended end-to-side anastomosis of the descending aorta to the distal ascending aorta was performed.", + "The anastomosis was performed with a continuous 7-0 polypropylene suture.", + "After removal of the aortic cross-clamp, full flow bypass was resumed.", + "The anastomosis was checked for bleeding.", + "The anastomosis was checked for undue tension.", + "The aortic cross-clamp was reapplied proximal to the aortic cannula.", + "Cardioplegia was infused again.", + "The aortopulmonary window repair was started.", + "The ascending aorta was transversely incised distal to the aortopulmonary window.", + "The aortopulmonary window was confirmed to be very large, 10 mm diameter.", + "The right pulmonary artery originated from the ascending aorta.", + "The left pulmonary artery arose from the pulmonary artery trunk in the normal fashion.", + "The coronary arteries were normally positioned.", + "The aortic cross clamp was removed and reapplied for right hemicerebral perfusion again.", + "A 4-0 Gore-tex patch was used to close the aortopulmonary window.", + "A 4-0 Gore-tex patch was used to separate the right pulmonary artery from the aortic origin.", + "After rewarming, cardiopulmonary bypass was easily weaned.", + "Total bypass time was 125 minutes.", + "Cross clamp time was 71 minutes.", + "One-third flow time was 66 minutes.", + "Peritoneal dialysis was performed post operatively for 3 days.", + "Peritoneal dialysis was switched with lasix intermittently.", + "The postoperative recovery was uneventful.", + "The neonate was extubated on the 7th day post operatively.", + "No clinical signs of neurologic disturbances were observed.", + "Cardiopulmonary function was satisfactory.", + "Distal perfusion was satisfactory.", + "Early postoperative echocardiography demonstrated an excellent early surgical result.", + "Early postoperative echocardiography showed a minimal pressure gradient of 12 mmHg across the aortic reconstruction.", + "Early postoperative echocardiography showed good left ventricular function.", + "Early postoperative echocardiography showed no residual aortopulmonary window.", + "In 2021, the patient was a 9 year old child.", + "The patient was cheerful.", + "The patient was growing actively.", + "The patient had entered elementary school in grade 2.", + "There were no abnormalities of the heart and lungs according to the patient's mother.", + "The patient had cerebral palsy sequela.", + "The cerebral palsy sequela was being treated by a pediatric neurologist." + ], + "summary": "We report a 9 days-old male neonates weighing 3.85 kg was referred by local hospital to our center and was ventilated with history of respiratory distress and severe infection since he was born. Admitted to our PCICU, 2D echo showed an IAA type A associated with a huge APW type II and restrictif PDA. A PGE1 infusion was started, during the following days the baby experienced several epileptic episodes. After improvement of the clinical condition, surgery was performed on the 20th days of life on year 2011. A successful one-stage repair of such anomalies in which cutting of PDA that arised from PA trunk and distally becoming into descending aorta, extended end to end anastomosis to conduct the ascending aortic blood flow into the descending aorta and intra arterial baffle was used. A 4-0 Gore-Tex baffle was used both to close the APW and separated the RPA from aortic origin with a good result, as his recently grown up as a cheerful 9 year old child who is growing actively and has entered elementary school in grade 2.", + "summary_subclaims": [ + "A 9 days-old male neonate weighing 3.85 kg was referred to our center.", + "The neonate was ventilated with a history of respiratory distress and severe infection since birth.", + "Admission was to the PCICU.", + "A 2D echo showed an IAA type A associated with a huge APW type II and restrictive PDA.", + "A PGE1 infusion was started.", + "The baby experienced several epileptic episodes during the following days.", + "Surgery was performed on the 20th day of life in 2011.", + "A successful one-stage repair of the anomalies was performed.", + "The repair included cutting of the PDA that arose from the PA trunk and distally became the descending aorta.", + "An extended end-to-end anastomosis was used to conduct ascending aortic blood flow into the descending aorta.", + "An intra-arterial baffle was used.", + "A 4-0 Gore-Tex baffle was used to close the APW and separate the RPA from the aortic origin.", + "The result was good, as the child recently grew up as a cheerful 9 year old.", + "The child is growing actively and has entered elementary school in grade 2." + ] + }, + { + "id": "multiclinsum_test_1375_en.txt", + "fulltext": "A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome for radiofrequency ablation. General physical examination was normal. Electrocardiography (ECG) showed pre-excitation in favor of left posterior accessory pathway (AP). Echocardiography was also normal.\nGuided by fluoroscopy, right atrium (RA), right ventricle, and coronary sinus catheters were introduced into the corresponding heart chambers. Basic electrophysiology study confirmed that AP was located in the posterior part of mitral valve ring; so we decided for TSP. This was the first time we used HeartSpan Steerable (Merit Medical Systems, South Jordan, UT, United States) sheath and the needle for TSP; in the previous TSP procedures, we used the AgilisTM sheath (Abbott, Saint Paul, MN, United States). Withdrawal of trans-septal sheath from superior vena cava into RA after 2 jumps usually places the introducer system in the fossa ovalis; but in this patient, this maneuver did not work despite several attempts. Finally, we could place the sheath into lower part of the interatrial septum, just above coronary sinus catheter in left anterior oblique projection. Jerky puncture with the needle was done and small amount of contrast injection showed that the needle has traversed the interatrial septum. So, we advanced the steerable sheath over the needle to the left side, and then the needle was withdrawn. However, to our surprise, contrast injection into the side branch of the sheath showed that it was in the left ventricle (LV) rather than the left atrium (-A). We advanced the 0.032” guidewire through the sheath to LV, and retracted the sheath to RA. Continuous arterial blood pressure monitoring did not show hemodynamic compromise, nor did echocardiography show pericardial effusion; so we decided to perform radiofrequency ablation of AP via the retrograde trans-aortic approach that was successful (-B).\nWe transferred the patient to coronary care unit (CCU) for better hemodynamic monitoring. On the next day, transthoracic and trans-esophageal echocardiography showed LV outflow tract to RA jet (-C and -D respectively). The patient was discharged uneventfully. Follow-up echocardiography showed that the tract was present for up to 18 months without any evidence of cardiac enlargement . Since the patient was asymptomatic, endovascular or surgical closure was not attempted.", + "fulltext_subclaims": [ + "A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome for radiofrequency ablation.", + "General physical examination was normal.", + "Electrocardiography (ECG) showed pre-excitation in favor of left posterior accessory pathway (AP).", + "Echocardiography was also normal.", + "Guided by fluoroscopy, right atrium (RA), right ventricle, and coronary sinus catheters were introduced into the corresponding heart chambers.", + "Basic electrophysiology study confirmed that AP was located in the posterior part of mitral valve ring.", + "We decided for TSP.", + "This was the first time we used HeartSpan Steerable sheath and the needle for TSP.", + "In the previous TSP procedures, we used the AgilisTM sheath.", + "Withdrawal of trans-septal sheath from superior vena cava into RA after 2 jumps usually places the introducer system in the fossa ovalis.", + "In this patient, this maneuver did not work despite several attempts.", + "We could place the sheath into lower part of the interatrial septum, just above coronary sinus catheter in left anterior oblique projection.", + "Jerky puncture with the needle was done.", + "Small amount of contrast injection showed that the needle has traversed the interatrial septum.", + "We advanced the steerable sheath over the needle to the left side, and then the needle was withdrawn.", + "Contrast injection into the side branch of the sheath showed that it was in the left ventricle (LV) rather than the left atrium.", + "We advanced the 0.032” guidewire through the sheath to LV, and retracted the sheath to RA.", + "Continuous arterial blood pressure monitoring did not show hemodynamic compromise.", + "Echocardiography did not show pericardial effusion.", + "We decided to perform radiofrequency ablation of AP via the retrograde trans-aortic approach.", + "Radiofrequency ablation via the retrograde trans-aortic approach was successful.", + "We transferred the patient to coronary care unit (CCU) for better hemodynamic monitoring.", + "On the next day, transthoracic and trans-esophageal echocardiography showed LV outflow tract to RA jet.", + "The patient was discharged uneventfully.", + "Follow-up echocardiography showed that the tract was present for up to 18 months.", + "Follow-up echocardiography showed no evidence of cardiac enlargement.", + "Since the patient was asymptomatic, endovascular or surgical closure was not attempted." + ], + "summary": "A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome. After trans-septal puncture, contrast injection into the sheath showed that it was in the left ventricle (LV) rather than left atrium. Trans-esophageal echocardiography confirmed left ventricle outflow tract to right atrial (RA) jet. Follow-up echocardiography showed that the tract was present up to 18 months, but considering that the patient was asymptomatic, endovascular or surgical closure was not done.", + "summary_subclaims": [ + "A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome.", + "Contrast injection into the sheath showed that it was in the left ventricle (LV) rather than left atrium.", + "Trans-esophageal echocardiography confirmed left ventricle outflow tract to right atrial (RA) jet.", + "Follow-up echocardiography showed that the tract was present up to 18 months.", + "Considering that the patient was asymptomatic, endovascular or surgical closure was not done." + ] + }, + { + "id": "multiclinsum_test_1974_en.txt", + "fulltext": "A 25-year-old female Nigerian patient presented with chief complaints of recurrent fever of 1 month duration and bilateral neck swelling. Fever was described as low grade, continuous, associated with chills and rigor, and relieved only by the use of paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs). She also noticed bilateral anterior neck swellings about 2 weeks prior to presentation. Swelling was gradual in onset, not painful, and about the size of a peanut when first noticed with no significant increase in size afterwards. Swelling remained the same with swallowing and without any pressure symptoms. She denied any history of cough or contact with a person with chronic cough, and had no history of hoarseness, dysphagia, odynophagia, or stridor. There were other associated symptoms of night sweats, recurrent headaches, nausea, anorexia, and weight loss of about 5 kg at the time of presentation.\nPrior to her visit at our outpatient department, she has had multiple medical consultations and multiple courses of antimalarial given over the 1 month period preceding her visit. However, her symptoms were persistent with no resolution. She had no significant past medical or surgical history. History of medications used prior to presentation included three courses (at varying points of illness) of artemether and lumefantrine combination, oral (PO) amoxicillin, PO clotrimazole, PO cotrimoxazole, and PO cefuroxime.\nPhysical examination findings revealed a young woman who was febrile with bilateral neck lump located at the bases of both the right and left anterior triangles of the neck, both measuring about 2 cm by 4 cm. Lumps were mildly tender and attached to underlying structure but not to the overlying skin. Vital signs at presentation: temperature 37.8 °C, pulse rate 96 beats per minute, blood pressure: 112/78 mmHg. There were no significant neurological, respiratory, cardiovascular, or abdominal findings.\nPreliminary laboratory investigations were essentially normal aside from an elevated erythrocyte sedimentation rate (ESR) value.\nComplete blood count:\nAn assessment of tuberculous adenitis was made to keep in view T-acute lymphoblastic leukemia.\nThe following further investigations were done:\nMantoux test—no induration after 72 hours. Chest X-ray—normal radiograph.\nNeck ultrasonography scan (USS): bilateral septated complex cystic masses measuring 3.86 by 2.31 cm and 3.19 cm by 1.31 cm in the right and left lateral region close to the cervical vascular bundles.\nThe patient was referred to a surgeon for further review, evaluation, and possible biopsy of the neck masses. A fine needle aspiration biopsy was opted for and done due to the peculiarity/difficult anatomy of neurovasculature in the neck region.\nFine needle aspiration cytology (FNAC): smear of aspirates showed sheets of small- to medium-sized lymphocytes, neutrophils, and few immunoblasts. Also seen are macrophages that are entrapped within fibrillary strands. No atypical cell was seen.\nOn the basis of these findings, an assessment of acute bacterial lymphadenitis was made and the patient was started on a course of PO levofloxacin for 2 weeks. The enlarged lymph nodes gradually regressed over the course of treatment, and on subsequent follow-up, the patient became symptom-free and has remained so.", + "fulltext_subclaims": [ + "The patient is a 25-year-old female Nigerian.", + "The patient had a fever of 1 month duration.", + "The fever was described as low grade, continuous, and associated with chills and rigor.", + "The fever was relieved only by the use of paracetamol and NSAIDs.", + "The patient noticed bilateral anterior neck swellings about 2 weeks prior to presentation.", + "The swelling was gradual in onset, not painful, and about the size of a peanut when first noticed.", + "The swelling remained the same with swallowing.", + "The patient had no history of cough or contact with a person with chronic cough.", + "The patient had no history of hoarseness, dysphagia, odynophagia, or stridor.", + "The patient had night sweats.", + "The patient had weight loss of about 5 kg at the time of presentation.", + "The patient had multiple courses of antimalarial given over the 1 month period preceding her visit.", + "The patient had no significant past medical or surgical history.", + "The patient had three courses of artemether and lumefantrine combination prior to presentation.", + "The patient had PO amoxicillin, PO clotrimazole, PO cotrimoxazole, and PO cefuroxime prior to presentation.", + "Physical examination revealed bilateral neck lumps located at the bases of both the right and left anterior triangles of the neck.", + "The lumps were mildly tender and attached to underlying structure but not to the overlying skin.", + "The temperature at presentation was 37.8 °C.", + "The ESR was elevated.", + "The complete blood count was essentially normal.", + "An assessment of tuberculous adenitis was made.", + "A Mantoux test showed no induration after 72 hours.", + "The chest X-ray was normal.", + "Neck ultrasonography showed bilateral septated complex cystic masses.", + "The patient was referred to a surgeon for further review.", + "A fine needle aspiration biopsy was done.", + "FNAC showed sheets of small- to medium-sized lymphocytes, neutrophils, and few immunoblasts.", + "Macrophaes entrapped within fibrillary strands were seen.", + "No atypical cell was seen.", + "An assessment of acute bacterial lymphadenitis was made.", + "The patient was started on a course of PO levofloxacin for 2 weeks.", + "The enlarged lymph nodes gradually regressed over the course of treatment.", + "On subsequent follow-up, the patient became symptom-free." + ], + "summary": "We present a case of delayed diagnosis of bacterial cervical lymphadenitis that initially presented with typical features of malaria from Plasmodium falciparum. A 26-year-old Nigerian woman presented to the outpatient department following complaints of a recurring fever of a month's duration and bilateral neck swelling of about 2 weeks prior to presentation.", + "summary_subclaims": [ + "This is a case of delayed diagnosis of bacterial cervical lymphadenitis.", + "The case initially presented with typical features of malaria from Plasmodium falciparum.", + "The patient is a 26-year-old Nigerian woman.", + "She presented to the outpatient department.", + "She had complaints of a recurring fever of a month's duration.", + "She had bilateral neck swelling of about 2 weeks prior to presentation." + ] + }, + { + "id": "multiclinsum_test_2683_en.txt", + "fulltext": "A 49-year-old Asian woman presented with severe abdominal distension and dyspnea. She suffered from the feeling of swelling abdomen, dull nature abdominal discomfort and pain, edema in both legs, and dyspnea from 3 weeks before her visit. She visited another hospital 2 days prior to her visit and was transferred to our emergency room owing to huge ovarian cystic mass occupying almost all of the abdominal cavity and large amount of left pleural effusion on computed tomography (CT) scan. On initial vital sign assessment, her blood pressure was stable and she had tachycardia but no fever. Her laboratory findings showed anemia (hemoglobin 8.3 g/dL), leukocytosis [white blood cells (WBC) 21.00 × 103/μL], C-reactive protein (CRP) elevation of 25.8 mg/dL with prolongation of prothrombin time (PT) (90.4 seconds), PT international normalized ratio (INR) , and activated partial thromboplastin time (aPTT) (no coagulation), which could possibly imply disseminated intravascular coagulation (DIC). Physical examination showed abdominal distension, severe tenderness, and rebound tenderness in the whole abdomen. Due to severe dyspnea and abdominal distension, chest arrow insertion at left lung and paracentesis were performed, draining approximately 850 mL and 2 L, respectively. While performing transfusion, we reexamined dynamic abdomen-pelvis CT scan and found 30-cm-sized multiseptated cystic mass and peritoneal thickening with large amount of ascites suggesting ovarian malignancy and peritoneal carcinomatosis . The patient’s preoperative cancer antigen 125 (CA125) level showed a significant increase with 674.3 U/mL, human epididymis protein 4 (HE4) was 286.4 pmol/L, and premenopausal/postmenopausal risk of ovarian malignancy algorithm (ROMA) index was 86.67%/92.83%. The other tumor markers such as carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), and alpha-fetoprotein (AFP) were within normal range. With all the results combined, rupture of a malignant ovarian tumor was suspected, and an emergent operation was planned.\nOn the initial operation findings, ruptured 30-cm-sized right ovarian multiseptated cystic mass showing diffuse adhesion to retroperitoneum, abdominal wall, and uterus was identified. Although frozen section biopsy from the right ovarian mass was revealed as a poorly differentiated carcinoma, debulking surgery including hysterectomy could not be performed owing to persistent oozing pattern bleeding from multiple sites, which was due to DIC. We performed bilateral salpingo-oophorectomy and partial omentectomy. The pathologic diagnosis of the right ovary was high-grade stromal sarcoma with features of brisk mitosis (30–40/high-power field), focal necrosis, adenofibromatous component, endometriosis with mucinous metaplasia, and hypercellular stroma . The tumor consisted of monotonous uniform cells with endometrial stromal differentiation . Mitotic figures were frequent , and highly atypical neoplastic cells were noted . Metastasis to omentum was also identified. On immunohistochemistry, tumor cells were positive for CD10 , Cyclin D1, and FOXL 2 and positive focally for desmin and smooth muscle actin (SMA). They were negative for beta-catenin and inhibin A. After the surgery, endometrial biopsy was done for excluding metastasis from the endometrium, and the pathologic result was nonspecific. The patient underwent adjuvant chemotherapy with three courses of Adriamycin (75 mg/m2). On the follow-up CT scan that was performed 6 months after the chemotherapy, new 11-mm-sized probable seeding nodules in the right omentum and left paracolic gutter were seen. A 1.5-cm-sized partly solid nodule in the right upper lung field was also identified on the chest CT. As for the lung lesion, we had both primary and metastatic lesion in mind, and planned to perform the surgery separately.\nWe performed the secondary debulking operation including total hysterectomy, metastasectomy, omentectomy, peritonectomy, appendectomy, and HIPEC (paclitaxel 175 mg/m2). In the final pathologic report, it was confirmed that the uterine cervix, myometrium, and endometrium had no specific finding except atrophy, which excludes the possibility of endometrial origin malignancy. Peritoneum, omentum, and appendix specimens were confirmed as metastatic high-grade endometrial stromal sarcoma. Two months after the surgery, the patient underwent another right upper lung lobectomy operation, and the biopsy was revealed as adenocarcinoma, which means double primary malignancy. Currently, she has been alive for 28 months under a new chemotherapy regimen: paclitaxel (175 mg/m2) and ifosfamide (1.6 g/m2).", + "fulltext_subclaims": [ + "The patient is a 49-year-old Asian woman.", + "She presented with severe abdominal distension and dyspnea.", + "She had a feeling of swelling abdomen.", + "She had dull nature abdominal discomfort and pain.", + "She had edema in both legs.", + "She had dyspnea for 3 weeks before her visit.", + "She visited another hospital 2 days prior to her visit.", + "She was transferred to the emergency room due to a huge ovarian cystic mass.", + "The CT scan showed a large amount of left pleural effusion.", + "On initial vital sign assessment, she had tachycardia.", + "Her hemoglobin was 8.3 g/dL.", + "Her white blood cells were 21.00 × 103/μL.", + "Her C-reactive protein was 25.8 mg/dL.", + "Her prothrombin time was 90.4 seconds.", + "Her PT international normalized ratio was prolonged.", + "Her activated partial thromboplastin time was not reported.", + "The coagulation tests could possibly imply disseminated intravascular coagulation.", + "Physical examination showed abdominal distension.", + "Physical examination showed severe tenderness in the whole abdomen.", + "Chest tube insertion at the left lung was performed.", + "Paracentesis was performed.", + "Approximately 850 mL of pleural fluid was drained.", + "Approximately 2 L of ascites was drained.", + "A dynamic abdomen-pelvis CT scan showed a 30-cm-sized multiseptated cystic mass.", + "The CT scan showed peritoneal thickening.", + "The CT scan showed large amount of ascites.", + "The findings suggested ovarian malignancy.", + "The findings suggested peritoneal carcinomatosis.", + "The patient's CA125 level was 674.3 U/mL.", + "The patient's HE4 was 286.4 pmol/L.", + "The premenopausal ROMA index was 86.67%.", + "The postmenopausal ROMA index was 92.83%.", + "CA19-9, CEA, and AFP were within normal range.", + "Rupture of a malignant ovarian tumor was suspected.", + "An emergent operation was planned.", + "The initial operation identified a ruptured 30-cm-sized right ovarian multiseptated cystic mass.", + "The mass showed diffuse adhesion to the retroperitoneum.", + "The mass showed diffuse adhesion to the abdominal wall.", + "The mass showed diffuse adhesion to the uterus.", + "Frozen section biopsy revealed poorly differentiated carcinoma.", + "Debulking surgery including hysterectomy could not be performed.", + "Bilateral salpingo-oophorectomy was performed.", + "Partial omentectomy was performed.", + "The pathologic diagnosis was high-grade stromal sarcoma.", + "The tumor showed features of brisk mitosis.", + "The tumor showed focal necrosis.", + "The tumor had an adenofibromatous component.", + "The tumor had endometriosis with mucinous metaplasia.", + "The tumor had hypercellular stroma.", + "The tumor consisted of monotonous uniform cells with endometrial stromal differentiation.", + "Mitotic figures were frequent.", + "Highly atypical neoplastic cells were noted.", + "Metastasis to the omentum was identified.", + "Tumor cells were positive for CD10.", + "Tumor cells were positive for Cyclin D1.", + "Tumor cells were positive for FOXL2.", + "Tumor cells were focally positive for desmin.", + "Tumor cells were focally positive for smooth muscle actin.", + "Tumor cells were negative for beta-catenin.", + "Tumor cells were negative for inhibin A.", + "Endometrial biopsy was performed.", + "The endometrial biopsy result was nonspecific.", + "The patient underwent three courses of Adriamycin chemotherapy.", + "A follow-up CT scan showed new 11-mm-sized probable seeding nodules in the right omentum.", + "A follow-up CT scan showed new 11-mm-sized probable seeding nodules in the left paracolic gutter.", + "A 1.5-cm-sized partly solid nodule was identified in the right upper lung field.", + "The lung lesion was considered both primary and metastatic.", + "A secondary debulking operation was planned.", + "The secondary debulking operation included total hysterectomy.", + "The secondary debulking operation included metastasectomy.", + "The secondary debulking operation included omentectomy.", + "The secondary debulking operation included peritonectomy.", + "The secondary debulking operation included appendectomy.", + "HIPEC with paclitaxel 175 mg/m2 was performed.", + "The final pathologic report confirmed no specific findings in the uterine cervix, myometrium, and endometrium.", + "The peritoneum, omentum, and appendix were confirmed as metastatic high-grade endometrial stromal sarcoma.", + "A right upper lung lobectomy was performed.", + "The lung biopsy was revealed as adenocarcinoma.", + "The patient has double primary malignancy.", + "The patient is currently alive 28 months after diagnosis.", + "The patient is under a new chemotherapy regimen: paclitaxel 175 mg/m2 and ifosfamide 1.6 g/m2." + ], + "summary": "A 49-year-old Asian woman presented with disseminated intravascular coagulation due to ruptured primary high-grade ovarian endometrial stromal sarcoma with multiple intraperitoneal metastases. After the initial surgery, the patient underwent adjuvant chemotherapy with three courses of Adriamycin (75 mg/m2). We performed the secondary debulking operation including total hysterectomy, metastasectomy, omentectomy, peritonectomy, appendectomy, and hyperthermic intraperitoneal chemotherapy (paclitaxel 175 mg/m2). Currently she has been alive for 28 months under a new chemotherapy regimen.", + "summary_subclaims": [ + "The patient is a 49-year-old Asian woman.", + "She presented with disseminated intravascular coagulation.", + "The cause of disseminated intravascular coagulation was ruptured primary high-grade ovarian endometrial stromal sarcoma.", + "The sarcoma had multiple intraperitoneal metastases.", + "The patient underwent adjuvant chemotherapy with three courses of Adriamycin.", + "The Adriamycin dose was 75 mg/m2.", + "The secondary debulking operation included total hysterectomy.", + "The secondary debulking operation included metastasectomy.", + "The secondary debulking operation included omentectomy.", + "The secondary debulking operation included peritonectomy.", + "The secondary debulking operation included appendectomy.", + "The secondary debulking operation included hyperthermic intraperitoneal chemotherapy.", + "The hyperthermic intraperitoneal chemotherapy used paclitaxel 175 mg/m2.", + "The patient has been alive for 28 months.", + "The patient is under a new chemotherapy regimen." + ] + }, + { + "id": "multiclinsum_test_1285_en.txt", + "fulltext": "A 65-year-old male farmer was admitted to the dermatology department of Lishui Central Hospital in April 2016 with the chief complaint of erythema, pruritus, and ulceration of the perianal skin combined with cough, which lasted for 1 year. One year ago, patient had perianal erythema, accompanied by pruritus, ulceration, exudation, and pain. Further questioning revealed that the patient had been coughing several times a day. The patient occasionally had white sputum, without any hemoptysis, chest pain, low grade fever, night sweats, or any other discomfort. The patient had applied a variety of ointments for external use, without improvement. The erythema gradually expanded, affecting half of the hip on both sides of the crissum; an ulcer developed at the center of the erythema. Past medical history included hepatitis B for more than 10 years, and hypertension for about 3 years. The patient had surgical history of cholecystectomy at 39 years of age and denied previous history of TB, tumor, being engaged in risky sexual behaviors, or similar family history. Physical examinations included body temperature of 36.9°C, blood pressure 133/86 mm Hg, pulse rate 86 beats/min, breathing 20 times/min, double pulmonary breath sounded rough without obvious rales. Physical examination by specialist showed a large erythematous plaque of about 20 cm × 15 cm around the anus, skin ulcers could be seen nearly 4 cm range at the perianal area, and the base could be seen with fresh granulation, and few purulent secretions (See Fig. ). Blood routine test, liver and kidney function tests, treponema pallidum particle agglutination assay (TPPA), toluidine red unheated serum test (TRUST), combined detection of human immunodeficiency virus (HIV) antibodies, and HIV antigens were all negative or within normal ranges. The detection and screening of alpha-fetoprotein (AFP) tumor marker, carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), total prostate specific antigen (TPSA), and free prostate-specific antigen (FPSA) were all normal. Blood sedimentation rate was 50.0 mm/h, TB DNA was positive, and TB antibody was positive. Acid-fast bacillus detection in sputum samples was ++++. Histological examination of perianal skin showed an ulcerative and necrotic area in the perianal skin, and peripheral epidermis had keratosis and hyperkeratosis. The stratum spinosum was proliferated, accompanied by intercellular edema. The whole dermis had epithelial-like cell mass, Langerhans giant cells could be seen, a large number of infiltrating lymphocytes were observed, and anti-acid staining was positive. Pathological diagnosis demonstrated (perianal skin) necrotic granulomatous lesions (TB). Special staining demonstrated acid-fast bacilli using acid-fast staining, periodic acid-Schiff stain (PAS) was negative (−), silver hexosamine stain was negative (−) (See Fig. ). Chest computed tomography (CT) scan showed symmetrical thorax, trachea moved to the right, and double lung marking increased and disordered. Diffuse nodular, flocculent, and striped high-density shadow could be seen in both the lungs, the edges were blurred, and the density was uneven. The partial lung tissues in both the upper lungs were consolidated and the cavity was formed. Hilus of the lung and mediastinal lymph nodes were not enlarged. The shape of the heart was not abnormal. There was no pleural effusion in the bilateral pleural cavity. Intrahepatic bile duct showed dilatation. Chest CT scan showed secondary pulmonary TB with cavitation in both upper lobes, and part of the right upper lung was damaged (See Fig. ). The results of abdominal enhanced CT showed intrahepatic bile duct dilatation and pneumobilia, gallbladder was not shown; splenomegaly, and multiple renal cysts in both the kidneys; possibility of duodenal descending diverticulum, and a little pneumatosis as a partial small intestinal obstruction. Admitting diagnosis showed perianal ulcerative skin TB, secondary bilateral pulmonary TB with possible cavity formation in the 2 upper lungs, TB bacillus was positive (+) in sputum smear. The patient was transferred to the infectious disease department for treatment, and was given with regular anti-TB treatment, which included isoniazid tablets 0.1 g/time, 3 times/day; rifampicin capsules 0.45 g/time, 1 time/day; ethambutol tablets 0.75 g/time, 1 time/day; pyrazinamide tablets 0.75 g/time, 2 times/day. The patient was discharged after 8 days of hospital treatment. M. tuberculosis in sputum smear was negative (−) at the time of discharge. Flushing and exudation of perianal skin were better than before. The patient was recommended to take regular anti-TB drugs for 6 months after discharge. After 6 months of discharge, the patient was followed up through telephone and replied that the ulcer had healed.", + "fulltext_subclaims": [ + "A 65-year-old male farmer was admitted to the dermatology department of Lishui Central Hospital in April 2016.", + "The patient's chief complaint was erythema, pruritus, and ulceration of the perianal skin combined with cough, which lasted for 1 year.", + "One year ago, the patient had perianal erythema, accompanied by pruritus, ulceration, exudation, and pain.", + "The patient occasionally had white sputum.", + "The patient had applied a variety of ointments for external use, without improvement.", + "The erythema gradually expanded, affecting half of the hip on both sides of the crissum.", + "An ulcer developed at the center of the erythema.", + "Past medical history included hepatitis B for more than 10 years.", + "The patient had surgical history of cholecystectomy at 39 years of age.", + "The patient denied previous history of TB.", + "Physical examination showed a large erythematous plaque of about 20 cm × 15 cm around the anus.", + "Skin ulcers could be seen nearly 4 cm range at the perianal area.", + "The base could be seen with fresh granulation.", + "Blood routine test, liver and kidney function tests, TPPA, TRUST, combined detection of HIV antibodies, and HIV antigens were all negative or within normal ranges.", + "Blood sedimentation rate was 50.0 mm/h.", + "TB DNA was positive.", + "TB antibody was positive.", + "Acid-fast bacillus detection in sputum samples was ++++.", + "Histological examination of perianal skin showed an ulcerative and necrotic area in the perianal skin.", + "Peripheral epidermis had keratosis and hyperkeratosis.", + "The stratum spinosum was proliferated, accompanied by intercellular edema.", + "The whole dermis had epithelial-like cell mass.", + "Langerhans giant cells could be seen.", + "A large number of infiltrating lymphocytes were observed.", + "Anti-acid staining was positive.", + "Pathological diagnosis demonstrated (perianal skin) necrotic granulomatous lesions (TB).", + "Special staining demonstrated acid-fast bacilli using acid-fast staining.", + "Chest CT scan showed secondary pulmonary TB with cavitation in both upper lobes.", + "Admitting diagnosis showed perianal ulcerative skin TB.", + "Admitting diagnosis showed secondary bilateral pulmonary TB with possible cavity formation in the 2 upper lungs.", + "TB bacillus was positive (+) in sputum smear.", + "The patient was given regular anti-TB treatment, which included isoniazid tablets 0.1 g/time, 3 times/day.", + "The patient was given regular anti-TB treatment, which included rifampicin capsules 0.45 g/time, 1 time/day.", + "The patient was given regular anti-TB treatment, which included ethambutol tablets 0.75 g/time, 1 time/day.", + "The patient was given regular anti-TB treatment, which included pyrazinamide tablets 0.75 g/time, 2 times/day.", + "The patient was discharged after 8 days of hospital treatment.", + "M. tuberculosis in sputum smear was negative (−) at the time of discharge.", + "Flushing and exudation of perianal skin were better than before.", + "The patient was recommended to take regular anti-TB drugs for 6 months after discharge.", + "After 6 months of discharge, the patient was followed up through telephone and replied that the ulcer had healed." + ], + "summary": "We present a case of a 65-year-old patient with perianal ulcer, which had been present for 1 year. Anamnesis revealed he had been persistently coughing for the same period of time. Histological examination of perianal skin showed necrotizing granulomatous lesions, acid-fast staining in sputum samples was ++++, TB antibody in the blood was positive, TB DNA test was positive, and chest scan that showed secondary pulmonary TB accompanied by possible pulmonary cavity formation in the 2 upper lungs.", + "summary_subclaims": [ + "The patient is a 65-year-old.", + "The patient had a perianal ulcer present for 1 year.", + "The patient had been persistently coughing for 1 year.", + "Histological examination of perianal skin showed necrotizing granulomatous lesions.", + "Acid-fast staining in sputum samples was ++++.", + "TB antibody in the blood was positive.", + "TB DNA test was positive.", + "Chest scan showed secondary pulmonary TB.", + "Chest scan showed possible pulmonary cavity formation in the 2 upper lungs." + ] + }, + { + "id": "multiclinsum_test_2432_en.txt", + "fulltext": "A 29-year-old woman with a history of out of hospital cardiac arrest with underlying ventricular fibrillation 4 months after delivery of her first child was referred to our centre to evaluate the risk of a second pregnancy. After her first pregnancy, the differential diagnosis of dilated cardiomyopathy vs. peripartum cardiomyopathy or primary electrical disease was made and an implantable cardioverter-defibrillator (ICD) was implanted as secondary prevention. Extensive investigations, including echocardiography and cardiac magnetic resonance imaging (MRI) revealed no abnormalities apart from mild mitral prolapse and mild left ventricular dysfunction.\nWhen she presented in our centre for counselling, she happened to be already 2 weeks pregnant. She had no complaints, no recent history of (pre)syncope’s. Clinical examination showed a lean woman (height 169 cm, weight 59 kg), with normal blood pressure 112/76 mmHg and an oxygen saturation of 98%. On auscultation, an apical mild systolic murmur was present with no signs of heart failure. The 12-lead electrocardiogram (ECG) demonstrated sinus rhythm with right bundle-branch block and ventricular extra systoles (PVC) . Exercise-ECG illustrated regular PVCs, no ST-segment changes, and moderate exercise capacity (81% of predicted maximal workload). Echocardiography showed a myxomatous mitral valve with some prolapse and mild to moderate regurgitation with normal left and right ventricular dimensions and function.\nIntensive follow-up both at the Department of Gynecology and Cardiology was arranged and the case was repeatedly discussed at the multidisciplinary pregnancy heart team in the presence of cardiologists, gynaecologists, and anaesthesiologists. The maternal risk for cardiac events was categorized as WHO class III and planned delivery with assisted vaginal delivery at our expert centre for pregnancy and cardiac disease was recommended. Medical treatment with metoprolol 100 mg/day was initiated. Prenatal foetal evaluation, genetic screening, and intensive follow-up of foetal growth under treatment with beta-blockers were provided. Pregnancy and delivery were uneventful. A healthy boy, birth weight 3040 g, was born after induction of labour at 39 weeks of pregnancy. She remained in the hospital for rhythm observation for 3 days. No cardiac events occurred in the peripartum period and on transthoracic echo her ventricular function remained good.\nHowever, 4 weeks later, she experienced a sudden syncope at home, while taking a shower. ICD interrogation revealed primary ventricular fibrillation, induced by a premature ventricular beat, terminated with a successful ICD shock. The morphology of the inducing beat could not be determined, since the recording of the intracardiac EGM starts after detection . A reversible cause like deterioration of left ventricular function or electrolyte imbalance was not found. Echocardiography revealed no new abnormalities. Medical treatment with metoprolol 100 mg/day was continued.\nShe mentioned having PVCs as an adolescent. Reviewing her ECGs showed the presence of regular right bundle-branch block ventricular extra systoles and a right superior axis, i.e. with an origin in the inferolateral basal left ventricle (i.e. close to the posterior mitral annulus) . A frame-by-frame echocardiographic analysis allowed the diagnosis of a MAD with detachment of the root of the annulus from the posterolateral ventricular myocardium during systole .\nRe-evaluation of the cardiac MRI made after her first cardiac arrest confirmed the presence of MAD inferolateral in late systole and detected no signs of fibrosis.\ndemonstrates an xPlane segmental analysis of the mitral valve and its annulus performed from the parasternal long-axis window with a lateral sweep at mitral annular level, orthogonal short-axis views are recorded on the secondary image. The xPlane image analysis of the mitral annulus illustrated clearly the presence of MAD at the posterior annulus and a normal anterior mitral annulus, explaining why the diagnosis of MAD can be missed when the cutting plane is incorrect .", + "fulltext_subclaims": [ + "The patient is a 29-year-old woman.", + "She had an out of hospital cardiac arrest.", + "The cardiac arrest was due to ventricular fibrillation.", + "The cardiac arrest occurred 4 months after delivery of her first child.", + "She was referred to evaluate the risk of a second pregnancy.", + "The differential diagnosis included dilated cardiomyopathy.", + "The differential diagnosis included peripartum cardiomyopathy.", + "The differential diagnosis included primary electrical disease.", + "An implantable cardioverter-defibrillator was implanted as secondary prevention.", + "Extensive investigations were performed.", + "Echocardiography revealed no abnormalities apart from mild mitral prolapse.", + "Echocardiography revealed no abnormalities apart from mild left ventricular dysfunction.", + "Cardiac MRI revealed no abnormalities apart from mild mitral prolapse.", + "Cardiac MRI revealed no abnormalities apart from mild left ventricular dysfunction.", + "When she presented for counselling, she was already 2 weeks pregnant.", + "She had no complaints.", + "She had no recent history of (pre)syncope.", + "Clinical examination showed a lean woman.", + "Her height was 169 cm.", + "Her weight was 59 kg.", + "Her blood pressure was 112/76 mmHg.", + "Her oxygen saturation was 98%.", + "A mild systolic murmur was heard on auscultation.", + "The 12-lead ECG demonstrated sinus rhythm.", + "The 12-lead ECG demonstrated right bundle-branch block.", + "The 12-lead ECG demonstrated ventricular extra systoles.", + "Exercise-ECG illustrated regular PVCs.", + "Exercise-ECG showed no ST-segment changes.", + "Exercise-ECG showed moderate exercise capacity.", + "Echocardiography showed a myxomatous mitral valve.", + "Echocardiography showed some prolapse.", + "Echocardiography showed mild to moderate regurgitation.", + "Echocardiography showed normal left and right ventricular dimensions.", + "Echocardiography showed normal left and right ventricular function.", + "Intensive follow-up at the Department of Gynecology was arranged.", + "Intensive follow-up at the Department of Cardiology was arranged.", + "The case was discussed at the multidisciplinary pregnancy heart team.", + "The maternal risk for cardiac events was categorized as WHO class III.", + "Planned delivery with assisted vaginal delivery was recommended.", + "Medical treatment with metoprolol 100 mg/day was initiated.", + "Prenatal foetal evaluation was provided.", + "Genetic screening was provided.", + "Intensive follow-up of foetal growth under treatment with beta-blockers was provided.", + "Pregnancy and delivery were uneventful.", + "A healthy boy was born.", + "The birth weight was 3040 g.", + "Labour was induced at 39 weeks.", + "She remained in the hospital for rhythm observation for 3 days.", + "No cardiac events occurred in the peripartum period.", + "Transthoracic echo showed good ventricular function.", + "Four weeks later, she experienced a sudden syncope at home.", + "ICD interrogation revealed primary ventricular fibrillation.", + "The ventricular fibrillation was induced by a premature ventricular beat.", + "The ICD shock was successful.", + "The morphology of the inducing beat could not be determined.", + "A reversible cause like deterioration of left ventricular function was not found.", + "A reversible cause like electrolyte imbalance was not found.", + "Echocardiography revealed no new abnormalities.", + "Medical treatment with metoprolol 100 mg/day was continued.", + "She mentioned having PVCs as an adolescent.", + "Reviewing her ECGs showed the presence of regular right bundle-branch block ventricular extra systoles.", + "Reviewing her ECGs showed a right superior axis.", + "The origin of the PVCs was in the inferolateral basal left ventricle.", + "A frame-by-frame echocardiographic analysis allowed the diagnosis of MAD.", + "The detachment of the root of the annulus from the posterolateral ventricular myocardium occurred during systole.", + "Re-evaluation of the cardiac MRI confirmed the presence of MAD inferolateral in late systole.", + "The cardiac MRI detected no signs of fibrosis.", + "The xPlane segmental analysis of the mitral valve and its annulus was performed from the parasternal long-axis window.", + "Orthogonal short-axis views were recorded.", + "The xPlane image analysis illustrated the presence of MAD at the posterior annulus.", + "The xPlane image analysis showed a normal anterior mitral annulus.", + "The diagnosis of MAD can be missed when the cutting plane is incorrect." + ], + "summary": "A 29-year-old woman survived an out of hospital cardiac arrest 4 months after delivery of her first child. The diagnosis was not clear and an implantable cardioverter-defibrillator (ICD) as secondary prevention was implanted. Her second pregnancy and delivery were uneventful. The 12-lead electrocardiogram demonstrated sinus rhythm with right bundle branch block, ventricular extra systoles (premature ventricular contractions), and a right superior axis, i.e. origin in the inferolateral basal left ventricle. Transthoracic 2D echocardiography showed myxomatous mitral valve disease with moderate mitral valve insufficiency with normal left and right heart dimensions and function. However, 4 weeks after delivery she experienced a sudden syncope at home. Implantable cardioverter-defibrillator reading revealed primary ventricular fibrillation, induced by a ventricular premature beat (VPB), terminated with a successful ICD shock. A frame-by-frame echocardiographic analysis of the mitral valve using biplane echocardiographic analysis allowed diagnosis of MAD with detachment of the root of the annulus from the posterolateral ventricular myocardium during systole.", + "summary_subclaims": [ + "The patient is a 29-year-old woman.", + "She survived an out of hospital cardiac arrest 4 months after delivery of her first child.", + "The diagnosis was not clear.", + "An implantable cardioverter-defibrillator (ICD) as secondary prevention was implanted.", + "Her second pregnancy and delivery were uneventful.", + "The 12-lead electrocardiogram demonstrated sinus rhythm with right bundle branch block.", + "The 12-lead electrocardiogram showed ventricular extra systoles (premature ventricular contractions).", + "The 12-lead electrocardiogram showed a right superior axis, i.e. origin in the inferolateral basal left ventricle.", + "Transthoracic 2D echocardiography showed myxomatous mitral valve disease.", + "Transthoracic 2D echocardiography showed moderate mitral valve insufficiency.", + "Transthoracic 2D echocardiography showed normal left and right heart dimensions and function.", + "4 weeks after delivery she experienced a sudden syncope at home.", + "Implantable cardioverter-defibrillator reading revealed primary ventricular fibrillation.", + "The ventricular fibrillation was induced by a ventricular premature beat (VPB).", + "The ventricular fibrillation was terminated with a successful ICD shock.", + "A frame-by-frame echocardiographic analysis of the mitral valve using biplane echocardiographic analysis allowed diagnosis of MAD.", + "MAD was diagnosed with detachment of the root of the annulus from the posterolateral ventricular myocardium during systole." + ] + }, + { + "id": "multiclinsum_test_1162_en.txt", + "fulltext": "A 20-year-old Greek man presented to our hospital in late May of 2010 because of high fever (up to 40°C, unresponsive to anti-inflammatory drugs), appetite loss, nausea and vomiting, persistent headache and a feeling of significant malaise for 5 days. He was diagnosed at a provincial hospital with an atypical infection and had received azithromycin for 3 days, without any improvement.\nHe had not travelled recently either within the country or abroad. He denied intravenous drug use, new sexual partners or tattoos. He had no animal exposure. He did not use tobacco products or alcohol and had not taken any medication. He was previously healthy. According to his medical history, he reported allergic rhinitis and conjunctivitis for his first 5 years of life, chickenpox at the age of 5 years, a streptococcal pneumonia at the age of 6 years, several episodes of tonsillitis until the age of 12 years and a tonsillar abscess at the age of 11 years. He reported no drug allergies. No contacts with similar symptoms were identified. He had no antecedents of Asian origin. The family history was non-contributory and no family members had rheumatic diseases.\nOn admission, his temperature was 38.3°C, blood pressure at 80/50mmHg, pulse was measured at 100 beats per minute and blood oxygen saturation at 92%. A physical examination revealed bilateral conjunctival chemosis, strawberry lips and tongue, dry mucus membranes, a mild skin rash of his trunk, erythema of his thenar and opisthenar regions of both palms, an oedema of palms and soles and tachycardia with S3 and S4 gallop. Results of examinations of his lungs, abdomen, neurological and musculoskeletal systems were normal.\nLaboratory findings revealed leucocytosis (13.2×103 per cubic millimetre) with neutrophilia (91%) and left shift with segmented neutrophils, anaemia (haematocrit 33%) and normal platelets upon admission, which were later elevated . Acute phase reactants were elevated: erythrocyte sedimentation rate (ESR), 127mm 1st hour; CRP, 30mg/dL and fibrinogen 761 seconds. Serum creatinine levels and serum glutamic oxaloacetic transaminase rates were normal, serum glutamic-pyruvic transaminase at 80IU/L, alkaline phosphatase at 147IU/L, gamma-glutamyl transpeptidase at 67IU/L, lactate dehydrogenase at 263IU/L, creatine kinase at 254IU/L, bilirubin was normal, albumin at 3.1g/dL and sodium at 132mmol/L. Urine analysis was normal. Results of blood and urine bacterial cultures and serological tests for bacteria and viruses were negative. Alpha 2 and gamma immunoglobulin levels were elevated. All blood tests for autoimmune diseases were negative. Immunophenotype examination revealed reduced cardinal number of CD3+CD8+ T lymphocytes. The results of a chest X-ray, an electrocardiogram and a transthoracic echocardiogram were normal.\nThe patient did not respond to broad-spectrum antibiotic treatment. Desquamation of his fingers and toes began on the seventh day since the disease onset. Autoimmune diseases and juvenile idiopathic arthritis were excluded, as he did not fulfil diagnostic criteria for any of these diseases. Drug hypersensitivity reactions could explain his clinical appearance; however, he was previously healthy and there was no need for him to take medication. Immediately after the suspicion of KD (on the 10th day after the onset of symptoms), he was given IVIG at 2000mg/kg once and aspirin at 50mg/kg orally for the first 3 days, and at 100mg per day for another 3 months. His treatment was based on the diagnostic criteria developed for KD in children because there had been no validated criteria for adult cases of KD. Antibiotic treatment was discontinued at this time.\nImmunoglobulin and aspirin had a striking result, since the patient was afebrile and in better condition on the very next day after the initiation of treatment. During the following days, all clinico-laboratory findings gradually improved and only a reactive thrombocytosis remained. In total, he remained hospitalised for 10 days. A computed tomography coronary angiography performed 1 month later showed no coronary aneurysms. Today, about 5 years later, our patient remains healthy.", + "fulltext_subclaims": [ + "The patient is a 20-year-old Greek man.", + "He presented in late May of 2010.", + "He had high fever up to 40°C.", + "The fever was unresponsive to anti-inflammatory drugs.", + "He had symptoms for 5 days.", + "He was diagnosed with an atypical infection at a provincial hospital.", + "He had received azithromycin for 3 days.", + "He had no recent travel within the country or abroad.", + "He denied intravenous drug use.", + "He had no animal exposure.", + "He did not use tobacco products or alcohol.", + "He had no antecedents of Asian origin.", + "On admission, his temperature was 38.3°C.", + "His blood pressure was 80/50mmHg.", + "His pulse was 100 beats per minute.", + "His blood oxygen saturation was 92%.", + "A physical examination revealed bilateral conjunctival chemosis.", + "He had strawberry lips and tongue.", + "He had a mild skin rash of his trunk.", + "He had erythema of his thenar and opisthenar regions of both palms.", + "He had oedema of palms and soles.", + "He had tachycardia with S3 and S4 gallop.", + "Laboratory findings revealed leucocytosis (13.2×103 per cubic millimetre).", + "Neutrophilia was 91%.", + "Acute phase reactants were elevated.", + "The ESR was 127mm 1st hour.", + "CRP was 30mg/dL.", + "Fibrinogen was 761 seconds.", + "Serum creatinine levels were normal.", + "Serum glutamic oxaloacetic transaminase rates were normal.", + "Serum glutamic-pyruvic transaminase was 80IU/L.", + "Alkaline phosphatase was 147IU/L.", + "Gamma-glutamyl transpeptidase was 67IU/L.", + "Lactate dehydrogenase was 263IU/L.", + "Creatine kinase was 254IU/L.", + "Bilirubin was normal.", + "Albumin was 3.1g/dL.", + "Sodium was 132mmol/L.", + "Urine analysis was normal.", + "Blood and urine bacterial cultures were negative.", + "Serological tests for bacteria and viruses were negative.", + "Alpha 2 and gamma immunoglobulin levels were elevated.", + "All blood tests for autoimmune diseases were negative.", + "Immunophenotype examination revealed reduced cardinal number of CD3+CD8+ T lymphocytes.", + "The results of a chest X-ray were normal.", + "The results of an electrocardiogram were normal.", + "The results of a transthoracic echocardiogram were normal.", + "The patient did not respond to broad-spectrum antibiotic treatment.", + "Desquamation of his fingers and toes began on the seventh day since the disease onset.", + "Autoimmune diseases and juvenile idiopathic arthritis were excluded.", + "Drug hypersensitivity reactions could explain his clinical appearance.", + "He was given IVIG at 2000mg/kg once.", + "He was given aspirin at 50mg/kg orally for the first 3 days.", + "He was given aspirin at 100mg per day for another 3 months.", + "His treatment was based on the diagnostic criteria developed for KD in children.", + "Antibiotic treatment was discontinued at this time.", + "Immunoglobulin and aspirin had a striking result.", + "The patient was afebrile and in better condition on the very next day after the initiation of treatment.", + "Computed tomography coronary angiography performed 1 month later showed no coronary aneurysms.", + "About 5 years later, the patient remains healthy." + ], + "summary": "A 20-year-old Greek man presented with high fever, appetite loss, nausea and vomiting, headache and significant malaise. He had an erythema of the palms and strikingly red lips and conjunctiva. As he did not respond to broad-spectrum antibiotics and after having excluded other possible diagnoses, the diagnosis of Kawasaki disease was set. He was treated with intravenous immunoglobulin and oral aspirin on the 10th day since the onset of the illness. His clinico-laboratory response was excellent and no coronary artery aneurysms were detected in coronary artery computed tomography performed 1 month later.", + "summary_subclaims": [ + "The patient is a 20-year-old Greek man.", + "He presented with high fever.", + "He had appetite loss.", + "He had nausea and vomiting.", + "He had headache.", + "He had significant malaise.", + "He had erythema of the palms.", + "He had strikingly red lips.", + "He had red conjunctiva.", + "He did not respond to broad-spectrum antibiotics.", + "Other possible diagnoses were excluded.", + "The diagnosis of Kawasaki disease was set.", + "He was treated with intravenous immunoglobulin.", + "He was treated with oral aspirin.", + "The treatment was given on the 10th day since the onset of the illness.", + "His clinico-laboratory response was excellent.", + "No coronary artery aneurysms were detected.", + "Coronary artery computed tomography was performed 1 month later." + ] + }, + { + "id": "multiclinsum_test_790_en.txt", + "fulltext": "A 73 year old male was admitted as an emergency in our department with symptoms and clinical signs suggesting SBO. The patient had undergone laparoscopic left colectomy for cancer of the descending colon, three years before. Abdominal imaging, including computed tomography with i.v. and per-os contrast, confirmed the diagnosis of obstruction of the mid-jejunum, without revealing any possible cause. After a 24-h period of clinical observation and conservative treatment, the patient underwent an exploratory laparatomy. The findings consisted of strangulated jejunal loops herniated through the mesocolic defect at the level of the colo-colonic anastomosis. Viability of the small bowel was ascertained and an intestinal resection was not considered necessary. An iatrogenic perforation of the colon at the level of the anastomosis during mobilization of the small bowel loops necessitated the exteriorization of the anastomosis in the form of a double barrel colostomy. The postoperative course was uneventful, and the patient was discharged on the 6th post-operative day .", + "fulltext_subclaims": [ + "The patient was a 73 year old male.", + "The patient was admitted as an emergency with symptoms and clinical signs suggesting SBO.", + "The patient had undergone laparoscopic left colectomy for cancer of the descending colon three years before.", + "Computed tomography with i.v. and per-os contrast confirmed the diagnosis of obstruction of the mid-jejunum.", + "Computed tomography did not reveal any possible cause of the obstruction.", + "After a 24-h period of clinical observation and conservative treatment, the patient underwent an exploratory laparatomy.", + "The findings consisted of strangulated jejunal loops herniated through the mesocolic defect at the level of the colo-colonic anastomosis.", + "Viability of the small bowel was ascertained.", + "An intestinal resection was not considered necessary.", + "An iatrogenic perforation of the colon at the level of the anastomosis occurred during mobilization of the small bowel loops.", + "The iatrogenic perforation necessitated the exteriorization of the anastomosis in the form of a double barrel colostomy.", + "The postoperative course was uneventful.", + "The patient was discharged on the 6th post-operative day." + ], + "summary": "A 73 year old male was admitted as an emergency with symptoms and clinical signs, suggesting obstruction of the small bowel. Abdominal imaging, including computed tomography confirmed the diagnosis. The patient had undergone laparoscopic left colectomy for cancer, three years ago. At laparotomy small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis. The small bowel loops were reduced and their viability was ascertained. Because of an iatrogenic perforation of the colon at the anastomosis during small bowel loops mobilization, the colon was temporarily exteriorized in the form of a double barrel colostomy. The postoperative course was uneventful.", + "summary_subclaims": [ + "The patient was a 73 year old male.", + "The patient was admitted as an emergency.", + "The patient had symptoms and clinical signs suggesting obstruction of the small bowel.", + "Abdominal imaging confirmed the diagnosis.", + "The patient had undergone laparoscopic left colectomy for cancer three years ago.", + "At laparotomy, small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis.", + "The small bowel loops were reduced.", + "The viability of the small bowel loops was ascertained.", + "An iatrogenic perforation of the colon at the anastomosis occurred during small bowel loops mobilization.", + "The colon was temporarily exteriorized in the form of a double barrel colostomy.", + "The postoperative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_1602_en.txt", + "fulltext": "A 49-year-old male Chinese HCC patient with chronic hepatitis B virus (HBV) infection (having lasted more than 20 years) and cirrhosis. The laboratory results showed the following: alanine aminotransferase (ALT) 43.4 U/L, aspartate aminotransferase (AST) 35.7 U/L, alkaline phosphatase (ALP) 200.5 U/L, gamma-glutamyl transpeptidase (GGT) 188.1 U/L, bilirubin (TBil) 15.5 μmol/L, and a-fetoprotein (AFP) > 2000 μg/L. Liver function of the patient was Child-Pugh A grade and preoperative indocyanine green retention rate (ICG) was 10.5%.\nComputed tomography (CT) showed a large mass about 11.3 × 9.9 cm2 in size in the right hepatic lobe, and a tumor thrombus (TT) in the right hepatic vein (RHV) extending into the IVC .\nUsing both his medical history and imaging findings, he was diagnosed with HCC associated with IVCTT. The clinical stage was BCLC stage C. The patient had no symptoms of right heart failure or pulmonary embolization at admission. Considering that the patient had normal hepatic function without distant metastasis, anterior approach right hepatectomy combined with IVC thrombectomy using trans-diaphragmatic intrapericardial IVC occlusion was planned for this patient .\nSurgery was performed via a subcostal inverse-L-shaped incision. At laparotomy, a tumor located in the right lobe of cirrhotic liver and no detectable ascites or peritoneal metastasis was observed. After the right hepatic artery and the right portal vein branch were ligated, hepatic parenchymal resection was performed using the clamp-crushing technique with inflow occlusion (Pringle’s maneuver) following the demarcation . Then the suprarenal IVC and portal vein were dissected and taped from the caudate lobe . The retrohepatic IVC below the confluence of the common channel of the left and middle hepatic veins was encircled by a vascular clamp. The diaphragm was transected via a vertical incision exposing the right atrial appendage. Then intraoperative ultrasonography was used to show that a TT in the RHV, involving the IVC, but it had not entered in the right atrium. The supradiaphragmatic IVC was encircled though trans-diaphragmatic intrapericardial IVC . The sequence of total hepatic vascular exclusion is shown in Fig. d and the IVTT was then removed en bloc successfully with Babcock forceps, the whole removal of IVCTT with IVC exclusion cost 20 min. The total operation required 481 min and the intraoperative hemorrhage was 900 ml.\nThe macroscopic findings of tumor measured 10 × 11 × 13 cm3 and the TT measured 3.0 × 2.0 cm2 . Postoperative histological diagnosis showed moderately differentiated HCC (grade II-III Edmondson) had invaded the right hepatic vein with hepatic fibrosis and intravascular tumor thrombus. No positive resection margins or local lymph node metastasis were observed microscopically . The TNM stage was T3bN0M0.\nPostoperative recovery was uneventful. The patient was discharged with few adverse events after the operation. The patient was disease-free at 32 months after the initial treatment .", + "fulltext_subclaims": [ + "The patient is a 49-year-old male Chinese HCC patient.", + "The patient has chronic hepatitis B virus (HBV) infection.", + "The HBV infection has lasted more than 20 years.", + "The patient has cirrhosis.", + "The patient's alanine aminotransferase (ALT) was 43.4 U/L.", + "The patient's aspartate aminotransferase (AST) was 35.7 U/L.", + "The patient's alkaline phosphatase (ALP) was 200.5 U/L.", + "The patient's gamma-glutamyl transpeptidase (GGT) was 188.1 U/L.", + "The patient's bilirubin (TBil) was 15.5 μmol/L.", + "The patient's a-fetoprotein (AFP) was > 2000 μg/L.", + "The patient's liver function was Child-Pugh A grade.", + "The patient's preoperative indocyanine green retention rate (ICG) was 10.5%.", + "Computed tomography (CT) showed a large mass about 11.3 × 9.9 cm2 in size in the right hepatic lobe.", + "CT showed a tumor thrombus (TT) in the right hepatic vein (RHV) extending into the IVC.", + "The patient was diagnosed with HCC associated with IVCTT.", + "The clinical stage was BCLC stage C.", + "The patient had no symptoms of right heart failure at admission.", + "The patient had no symptoms of pulmonary embolization at admission.", + "The patient had normal hepatic function.", + "The patient had no distant metastasis.", + "Anterior approach right hepatectomy combined with IVC thrombectomy using trans-diaphragmatic intrapericardial IVC occlusion was planned.", + "Surgery was performed via a subcostal inverse-L-shaped incision.", + "At laparotomy, a tumor located in the right lobe of cirrhotic liver was observed.", + "No detectable ascites was observed at laparotomy.", + "No detectable peritoneal metastasis was observed at laparotomy.", + "The right hepatic artery and the right portal vein branch were ligated.", + "Hepatic parenchymal resection was performed using the clamp-crushing technique with inflow occlusion.", + "The suprarenal IVC and portal vein were dissected and taped from the caudate lobe.", + "The retrohepatic IVC below the confluence of the common channel of the left and middle hepatic veins was encircled by a vascular clamp.", + "The diaphragm was transected via a vertical incision exposing the right atrial appendage.", + "Intraoperative ultrasonography showed that a TT in the RHV, involving the IVC, but it had not entered in the right atrium.", + "The supradiaphragmatic IVC was encircled though trans-diaphragmatic intrapericardial IVC.", + "The IVTT was then removed en bloc successfully with Babcock forceps.", + "The whole removal of IVCTT with IVC exclusion cost 20 min.", + "The total operation required 481 min.", + "The intraoperative hemorrhage was 900 ml.", + "The macroscopic findings of tumor measured 10 × 11 × 13 cm3.", + "The TT measured 3.0 × 2.0 cm2.", + "Postoperative histological diagnosis showed moderately differentiated HCC (grade II-III Edmondson).", + "The HCC had invaded the right hepatic vein.", + "Hepatic fibrosis was observed.", + "Intravascular tumor thrombus was observed.", + "No positive resection margins were observed microscopically.", + "No local lymph node metastasis was observed microscopically.", + "The TNM stage was T3bN0M0.", + "Postoperative recovery was uneventful.", + "The patient was discharged with few adverse events after the operation.", + "The patient was disease-free at 32 months after the initial treatment." + ], + "summary": "Herein we report a case of HCC with IVC tumor thrombosis extending from the right hepatic vein (RHV) to the IVC, but it had not infiltrated the right atrium. Anterior approach right hepatectomy combined with IVC thrombectomy using trans-diaphragmatic IVC occlusion was performed for this patient. The patient is alive with disease-free at 32 months after treatment. A literature review was also performed. This case was demonstrated with the details and concepts of surgery.", + "summary_subclaims": [ + "The case involves HCC with IVC tumor thrombosis extending from the right hepatic vein to the IVC.", + "The tumor thrombosis had not infiltrated the right atrium.", + "Anterior approach right hepatectomy combined with IVC thrombectomy was performed.", + "Trans-diaphragmatic IVC occlusion was used during the procedure.", + "The patient is alive with disease-free status at 32 months after treatment.", + "A literature review was also performed.", + "This case was demonstrated with the details and concepts of surgery." + ] + }, + { + "id": "multiclinsum_test_1046_en.txt", + "fulltext": "The patient, an 11-year-old female, has been suffering of short stature for 6 years before being admitted to the hospital. The girl was the fifth child born to a nonconsanguineous couple. She was born naturally at full term, with a low birth weight and height, and was breastfed. After the age of 5, the patient’s height is lower than that of children of the same age. After admission to our hospital, Blood tests showed the decreased levels of phosphorus to 0.80 mmol/L (normal range: 0.96–1.62 mmol/L), 1,25-(OH)2-D to 11.39 pg/ml (normal range: 20–100 pg/ml), tubular reabsorption of phosphate (TRP) to 83.7% (normal range: 84 to 96%) and increased levels of alkaline phosphatase to 1427.40 U/L (normal range: 45–125 U/L). The other electrolytes, thyroid hormone, 24-hour urine calcium levels and ratio of maximum rate of renal tubular reabsorption of phosphate to glomerular filtration rate (TMP/GFR) were unremarkable. The patient’s siblings and parents blood phosphorus results revealed that one of the patient’s sisters had low blood phosphorus, and bowed legs were the only clinical manifestation. Here are the patient’s laboratory test results along with their corresponding normal reference ranges.\nTable Phosphate clearance test results: after consuming 300 ml of distilled water on an empty stomach, the following measurements were taken 2 hours later; TRP: tubular reabsorption of phosphate; TMP/GFR: ratio of maximum rate of renal tubular reabsorption of phosphate to glomerular filtration rate.\nHand X-ray showed left distal ulnar radius consistent with rickets in active phase , radiographs of growth plates demonstrate metaphyseal widening, cupping, lucency and flaring, possible old fracture of the distal radius on the left side, and bone age comparable to the girl’s standard of 9 years; renal scan suggested a strong echogenic cluster of about 6 mm in the right renal pelvis and calyces ; the chest radiograph showed reduced bone density in the bones within the scan area ; previous bone X-rays of both hands suggested that the hands and wrist joints were dysplastic and rickets was considered; radiographs of both lower limbs suggested that rickets was present in both lower limbs with bowed legs. Pure tone audiometry: the average hearing threshold at speech frequencies of 20 dB in both ears. The conductance map shows a binaural (type A) curve, no otoacoustic emissions elicited in either ear. Auditory brainstem: binaural hearing thresholds of 25dBnHL, suggestive of normal hearing.\nA case is reported in this paper. The proband’s parents are not consanguineous. With the informed consent of the patients and family members, whole exome sequencing analysis was performed and showed that the proband harbored the c.1402C > T; p.R468W in theSLC34A3gene , this variant has been described by Bergwitz et al. 2006 . Sanger sequencing was performed to verify this variant in other family members. The proband’s mother and father carry a heterozygous variant of the gene, and the proband’s sister had a homozygous variant. The proband also harbored a c.3917C > T (p.A1306V) homozygous variant in theLRP5gene . The proband’s mother and father carried a heterozygous variant in the gene, but the proband’s sister was normal.\nTherefore, combined with the clinical manifestations of the patient, the genetic testing results and family analysis can be used to diagnose hereditary hypophosphatemic rickets with hypercalciuria. The relevant manifestations of the patient and her relatives are as follows .", + "fulltext_subclaims": [ + "The patient is an 11-year-old female.", + "The patient has been suffering from short stature for 6 years before being admitted to the hospital.", + "The patient was born naturally at full term.", + "The patient had low birth weight and height.", + "The patient was breastfed.", + "After the age of 5, the patient’s height is lower than that of children of the same age.", + "Blood tests showed decreased levels of phosphorus to 0.80 mmol/L.", + "The normal range for phosphorus is 0.96–1.62 mmol/L.", + "Blood tests showed decreased levels of 1,25-(OH)2-D to 11.39 pg/ml.", + "The normal range for 1,25-(OH)2-D is 20–100 pg/ml.", + "Blood tests showed increased levels of alkaline phosphatase to 1427.40 U/L.", + "The normal range for alkaline phosphatase is 45–125 U/L.", + "The patient’s tubular reabsorption of phosphate (TRP) was 83.7%.", + "The normal range for TRP is 84 to 96%.", + "The patient’s siblings and parents blood phosphorus results revealed that one of the patient’s sisters had low blood phosphorus.", + "The patient’s sister had bowed legs as the only clinical manifestation.", + "Hand X-ray showed left distal ulnar radius consistent with rickets in active phase.", + "Radiographs of growth plates demonstrate metaphyseal widening, cupping, lucency and flaring.", + "A possible old fracture of the distal radius on the left side was noted.", + "Bone age was comparable to the girl’s standard of 9 years.", + "A renal scan suggested a strong echogenic cluster of about 6 mm in the right renal pelvis and calyces.", + "The chest radiograph showed reduced bone density in the bones within the scan area.", + "Previous bone X-rays of both hands suggested that the hands and wrist joints were dysplastic and rickets was considered.", + "Radiographs of both lower limbs suggested that rickets was present in both lower limbs with bowed legs.", + "Pure tone audiometry showed an average hearing threshold at speech frequencies of 20 dB in both ears.", + "The conductance map shows a binaural (type A) curve.", + "No otoacoustic emissions were elicited in either ear.", + "Auditory brainstem showed binaural hearing thresholds of 25dBnHL.", + "The proband’s parents are not consanguineous.", + "Whole exome sequencing analysis showed that the proband harbored the c.1402C > T; p.R468W variant in the SLC34A3 gene.", + "The c.1402C > T; p.R468W variant in the SLC34A3 gene has been described by Bergwitz et al. 2006.", + "Sanger sequencing was performed to verify this variant in other family members.", + "The proband’s mother and father carry a heterozygous variant of the SLC34A3 gene.", + "The proband’s sister had a homozygous variant in the SLC34A3 gene.", + "The proband also harbored a c.3917C > T (p.A1306V) homozygous variant in the LRP5 gene.", + "The proband’s mother and father carried a heterozygous variant in the LRP5 gene.", + "The proband’s sister was normal.", + "Combined with the clinical manifestations of the patient, the genetic testing results and family analysis can be used to diagnose hereditary hypophosphatemic rickets with hypercalciuria." + ], + "summary": "We report a 11-year-old female proband, who was admitted to our hospital with bilateral genuvarum deformity and short stature. Computed Tomography (CT) showed kidney stones, blood tests showed hypophosphatemia, For a clear diagnosis, we employed high-throughput sequencing technology to screen for variants. Our gene sequencing approach encompassed whole exome sequencing, detection of exon and intron junction regions, and examination of a 20 bp region of adjacent introns. Flanking sequences are defined as ±50 bp upstream and downstream of the 5' and 3' ends of the coding region.The raw sequence data were compared to the known gene sequence data in publicly available sequence data bases using Burrows-Wheeler Aligner software (BWA, 0.7.12-r1039), and the pathogenic variant sites were annotated using Annovar. Subsequently, the suspected pathogenic variants were classified according to ACMG's gene variation classification system. Simultaneously, unreported or clinically ambiguous pathogenic variants were predicted and annotated based on population databases. Any suspected pathogenic variants identified through this analysis were then validated using Sanger sequencing technology. At last, the proband and her affected sister carried pathogenic homozygous variant in the geneSLC34A3(exon 13, c.1402C > T; p.R468W). Their parents were both heterozygous carriers of the variant. Genetic testing revealed that the patient has anLRP5(exon 18, c.3917C > T; p.A1306V) variant of Uncertain significance, which is a rare homozygous variant.", + "summary_subclaims": [ + "The patient is a 11-year-old female.", + "The patient had bilateral genuvarum deformity.", + "The patient had short stature.", + "Computed Tomography showed kidney stones.", + "Blood tests showed hypophosphatemia.", + "High-throughput sequencing technology was used to screen for variants.", + "The gene sequencing approach encompassed whole exome sequencing.", + "The gene sequencing approach included detection of exon and intron junction regions.", + "The gene sequencing approach included examination of a 20 bp region of adjacent introns.", + "Flanking sequences are defined as ±50 bp upstream and downstream of the 5' and 3' ends of the coding region.", + "The raw sequence data were compared to the known gene sequence data in publicly available sequence databases using BWA software version 0.7.12-r1039.", + "Pathogenic variant sites were annotated using Annovar.", + "Suspected pathogenic variants were classified according to ACMG's gene variation classification system.", + "Unreported or clinically ambiguous pathogenic variants were predicted and annotated based on population databases.", + "Suspected pathogenic variants identified through this analysis were validated using Sanger sequencing technology.", + "The proband and her affected sister carried a pathogenic homozygous variant in the SLC34A3 gene.", + "The variant in SLC34A3 was located in exon 13, c.1402C > T; p.R468W.", + "The parents were both heterozygous carriers of the SLC34A3 variant.", + "Genetic testing revealed an LRP5 variant in the patient.", + "The LRP5 variant was located in exon 18, c.3917C > T; p.A1306V.", + "The LRP5 variant was classified as a variant of Uncertain significance.", + "The LRP5 variant is a rare homozygous variant." + ] + }, + { + "id": "multiclinsum_test_1581_en.txt", + "fulltext": "A 72-year-old Caucasian man with a history of prostate cancer, central serous retinopathy, obstructive sleep apnea, type 2 diabetes mellitus, hypertension, and mild chronic obstructive pulmonary disease but no known coronary artery disease or history of neurologic disorders was first diagnosed with left lower lobe non-small cell lung cancer (NSCLC) in 2013, for which he underwent a left lower lobectomy that same year. On surveillance imaging in 2014, he was noted to have a right lower lobe nodule and was diagnosed with a second primary NSCLC, for which he underwent stereotactic body radiation therapy (SBRT). In 2017, he was noted to have an enlarging left upper lobe nodule that was treated with SBRT. Surveillance CT imaging in September 2018 was significant for an enlarging right upper lobe nodule with right paratracheal lymph node involvement. Subsequent positron emission tomography (PET)-CT revealed several FDG-avid mediastinal and right hilar nodes concerning for malignancy. Metastatic bronchogenic adenocarcinoma was confirmed via endobronchial ultrasound with transbronchial needle aspiration, with pathology showing 5/5 positive lymph nodes. PD-L1 immunohistochemistry 22C3 (Keytruda) testing of the lymph node revealed high PD-L1 expression with 80% tumor proportion score. MRI of the brain was negative for intracranial metastatic disease. He was diagnosed with TxN3M0 stage IIIB adenocarcinoma and was treated with six cycles of weekly cisplatin and SBRT. He then initiated adjuvant durvalumab for maintenance therapy, receiving two cycles (10 mg/kg) on treatment days 0 and 15. Our patient subsequently presented to the emergency department on day 18 with a 4-day history of shortness of breath, weakness, and chest pressure. Workup on admission was significant for lateral lead ST elevations with an initial troponin of 7.1 ng/dL. He emergently underwent a left heart catheterization, which was negative for obstructive coronary artery disease. Transthoracic echocardiogram was significant for a normal ejection fraction with mild left ventricular concentric hypertrophy.\nAdmission diagnosis was myopericarditis of unclear etiology. On hospital day 4, he was noted to have persistently elevated levels of serum troponin, peaking at 12 ng/mL. His levels of serum creatinine kinase (CK) were elevated as well, peaking at 9262 U/L. He had persistent mild hepatocellular transaminitis (peak AST 72, ALT 531). The use of corticosteroids was discussed with the patient owing to concern for irAE; however the patient declined on the basis of his central serous retinopathy. He was noted to have dysphagia on admission with regurgitation of solids and liquids. A barium swallow study and esophagogastroduodenoscopy on hospital day 3 did not reveal any structural abnormalities. On hospital day 9, the patient developed progressive axial weakness, with increasing difficulty holding his head upright while seated. Neurology was consulted, who had a high concern for myasthenic crisis, which was subsequently confirmed by decreased negative inspiratory forces and elevated acetylcholine receptor binding and blocking antibodies. Due to his declining respiratory status, he was transferred to the intensive care unit (ICU) and intubated on the same day for airway protection. MRI of the brain performed on hospital day 10 was significant for 12 new metastatic lesions with surrounding vasogenic edema. The patient was started on high-dose corticosteroids at 1 mg/kg/day and underwent plasmapheresis on hospital day 10, completing 5 rounds. Unfortunately, he was unable to be weaned from mechanical ventilation and required tracheostomy placement as well as percutaneous endoscopic gastrostomy nutrition.\nAfter multiple goals-of-care discussions, the patient was transferred from the ICU to a long-term acute care facility owing to mechanical ventilation dependence, on hospital day 36. Diagnoses of myopericarditis, myositis, and myasthenic crisis were attributed to immune-mediated response to durvalumab.", + "fulltext_subclaims": [ + "The patient is a 72-year-old Caucasian man.", + "He has a history of prostate cancer.", + "He has a history of central serous retinopathy.", + "He has a history of obstructive sleep apnea.", + "He has a history of type 2 diabetes mellitus.", + "He has a history of hypertension.", + "He has a history of mild chronic obstructive pulmonary disease.", + "He has no known coronary artery disease.", + "He has no history of neurologic disorders.", + "He was first diagnosed with left lower lobe non-small cell lung cancer in 2013.", + "He underwent a left lower lobectomy in 2013.", + "On surveillance imaging in 2014, he was noted to have a right lower lobe nodule.", + "He was diagnosed with a second primary non-small cell lung cancer in 2014.", + "He underwent stereotactic body radiation therapy for the second primary non-small cell lung cancer.", + "In 2017, he was noted to have an enlarging left upper lobe nodule.", + "The enlarging left upper lobe nodule was treated with stereotactic body radiation therapy.", + "Surveillance CT imaging in September 2018 was significant for an enlarging right upper lobe nodule.", + "The right upper lobe nodule was associated with right paratracheal lymph node involvement.", + "Subsequent positron emission tomography (PET)-CT revealed several FDG-avid mediastinal and right hilar nodes.", + "The mediastinal and right hilar nodes were concerning for malignancy.", + "Metastatic bronchogenic adenocarcinoma was confirmed via endobronchial ultrasound with transbronchial needle aspiration.", + "Pathology showed 5/5 positive lymph nodes.", + "PD-L1 immunohistochemistry 22C3 testing of the lymph node revealed high PD-L1 expression.", + "The PD-L1 tumor proportion score was 80%.", + "MRI of the brain was negative for intracranial metastatic disease.", + "He was diagnosed with TxN3M0 stage IIIB adenocarcinoma.", + "He was treated with six cycles of weekly cisplatin and stereotactic body radiation therapy.", + "He then initiated adjuvant durvalumab for maintenance therapy.", + "He received two cycles of durvalumab at 10 mg/kg on treatment days 0 and 15.", + "He presented to the emergency department on day 18 with a 4-day history of shortness of breath, weakness, and chest pressure.", + "Workup on admission was significant for lateral lead ST elevations.", + "The initial troponin was 7.1 ng/dL.", + "He emergently underwent left heart catheterization.", + "The left heart catheterization was negative for obstructive coronary artery disease.", + "Transthoracic echocardiogram was significant for a normal ejection fraction.", + "The echocardiogram showed mild left ventricular concentric hypertrophy.", + "The admission diagnosis was myopericarditis of unclear etiology.", + "On hospital day 4, he was noted to have persistently elevated levels of serum troponin.", + "The serum troponin peaked at 12 ng/mL.", + "His levels of serum creatinine kinase were elevated, peaking at 9262 U/L.", + "He had persistent mild hepatocellular transaminitis, with peak AST 72 and ALT 531.", + "The use of corticosteroids was discussed with the patient owing to concern for immune-related adverse event.", + "The patient declined corticosteroids on the basis of his central serous retinopathy.", + "He was noted to have dysphagia on admission with regurgitation of solids and liquids.", + "A barium swallow study and esophagogastroduodenoscopy on hospital day 3 did not reveal any structural abnormalities.", + "On hospital day 9, the patient developed progressive axial weakness.", + "Neurology was consulted, who had a high concern for myasthenic crisis.", + "Myasthenic crisis was confirmed by decreased negative inspiratory forces and elevated acetylcholine receptor binding and blocking antibodies.", + "Due to his declining respiratory status, he was transferred to the intensive care unit.", + "He was intubated on hospital day 9 for airway protection.", + "MRI of the brain performed on hospital day 10 was significant for 12 new metastatic lesions.", + "The metastatic lesions were associated with surrounding vasogenic edema.", + "The patient was started on high-dose corticosteroids at 1 mg/kg/day.", + "He underwent plasmapheresis on hospital day 10, completing 5 rounds.", + "He was unable to be weaned from mechanical ventilation.", + "He required tracheostomy placement.", + "He required percutaneous endoscopic gastrostomy nutrition.", + "After multiple goals-of-care discussions, he was transferred from the ICU to a long-term acute care facility.", + "The transfer occurred on hospital day 36.", + "The transfer was due to mechanical ventilation dependence.", + "Diagnoses of myopericarditis, myositis, and myasthenic crisis were attributed to immune-mediated response to durvalumab." + ], + "summary": "We present the case of a 72-year-old Caucasian man with non-small cell lung cancer who was admitted for dyspnea after two cycles of durvalumab. He was found to have significantly elevated levels of serum creatinine kinase and troponin with a negative cardiac catheterization. During his hospitalization, he developed progressive dyspnea and new-onset axial weakness, ultimately leading to the diagnosis of durvalumab-induced myocarditis, myasthenia gravis, and myositis.", + "summary_subclaims": [ + "The patient was a 72-year-old Caucasian man.", + "The patient had non-small cell lung cancer.", + "The patient was admitted for dyspnea after two cycles of durvalumab.", + "The patient had significantly elevated levels of serum creatinine kinase.", + "The patient had significantly elevated levels of troponin.", + "The patient had a negative cardiac catheterization.", + "The patient developed progressive dyspnea during hospitalization.", + "The patient developed new-onset axial weakness.", + "The patient was diagnosed with durvalumab-induced myocarditis.", + "The patient was diagnosed with myasthenia gravis.", + "The patient was diagnosed with myositis." + ] + }, + { + "id": "multiclinsum_test_2672_en.txt", + "fulltext": "A 77-year-old woman was referred to our department after she requested surgical treatment for a tumor located near the gastric fornix. She underwent a preventive esophagogastroduodenoscopy 2 years and 7 months prior to the referral. The examination had revealed a submucosal tumor-like lesion in the fornix, which measured 10 mm. After this diagnosis, she was referred to her previous physician. Contrast enhanced computed tomography (CT) revealed a low density, round mass, measuring approximately 20 mm that was located between the upper stomach and left lateral segment of the liver . Additionally, magnetic resonance imaging (MRI) revealed that the mass showed a high signal intensity on T2-weighted imaging and seemed to be distinct from the stomach . It was determined that the tumor would require careful follow-up. A follow-up MRI was performed 5 months later, and it showed slight growth of the tumor. An endoscopic ultrasonography (EUS) was also performed, and it revealed a cystic structure continuous with the gastric wall. Contrary to the previous CT and MRI results that suggested the presentation of an extra-gastric tumor, the EUS results suggested that a gastrointestinal stromal tumor (GIST) could not be ruled out. Owing to the conflicting results, the patient was referred to the endoscopy division of our hospital two years ago for detailed examination. On admission, abnormal symptoms such as fever, anemia, and jaundice were not observed, and her performance status was good (Eastern Cooperative Oncology Group score of 0). She had a history of Sjögren syndrome but had no history of other systemic diseases such as diabetes and hypertension. She had no history of smoking and alcohol abuse. Additionally, she had no family history of malignant diseases. Laboratory studies were within normal range. The EUS was re-examined, and it was concluded that the cystic tumor with solid components did not to originate from either the liver or the stomach. Fine-needle aspiration biopsy was not performed considering the risk of tumor dissemination (according to Japanese Clinical Practice Guidelines for GIST, 3rd edition, it is contraindicated to perform EUS-FNA for extramurally grown submucosal tumor ). The differential diagnoses considered for the tumor were bronchogenic cyst, epidermoid cyst, lymph node with cystic degeneration, and neurogenic tumor. Since a few malignant findings were observed, regular follow-ups were recommended for the patient. These examinations indicated that there was gradual growth in the size of the tumor. A follow-up EUS performed 1 year and 6 months after admission revealed that the cystic tumor had grown to 25 mm in diameter, and there seemed to be no continuity between the tumor and the stomach . However, the CT scan showed an unclear part of the boundary between the tumor and the gastric wall . We could not completely exclude the possibility of GIST, and we explained the results to the patient. She requested surgical resection, following which we planned for a surgery at our division.\nSince the tumor was rather small (less than 3 cm in diameter), we decided to resect the tumor using laparoscopic approach. The tumor was located close to the upper stomach, and we planned to place the trocars using the same arrangement as in upper gastrointestinal surgery. The patient was placed in the supine position with legs apart; the brunt port was inserted from the umbilicus; a 12 mm trocar and three 5 mm trocars were placed in the reverse trapezoid position in the upper abdomen; and the Nathanson’s retractor (HEIWA MEDICAL INSTRUMENTS Co., Ltd. Bofu, Yamaguchi, Japan) was placed in the epigastrium as the liver retractor . An initial laparoscopic examination revealed a firm, completely encapsulated mass located on the left of the diaphragm . Since the tumor was relatively small and visibility was good, we decided to continue with the laparoscopic approach. Partial diaphragmectomy with complete inclusion of the tumor was performed using laparoscopic coagulation shears . The tumor was packed in a plastic bag and then extracted via the umbilical incision. The defect of the diaphragm was directly closed by a running suture using the 3-0 V-Loc™ absorbable suture (Medtronic plc, Minneapolis, MS, USA) . The total operating time was 59 min. The intraoperative blood loss was negligible. A video recording of the surgical procedure has been provided in the Additional file .\nThe tumor measured 2.5 × 2.0 × 1.8 cm and was well encapsulated . The cut section of the tumor showed a tan or yellow solid component and cystic abnormalities. On microscopic examination, it was found that the tumor was surrounded by a pink fibrous capsule with a cystic area . Under low magnification power, the tumor showed a pattern of alternating highly cellular Antoni type A and less cellular Antoni type B areas . The tumor was composed of spindle cells with bland, twisted nuclei and indistinct cytoplasmic border arranged in short bundles or interlacing fascicles . In the Antoni type A area, the spindle cells showed nuclear palisading. Upon immunohistochemical analysis, the tumor cells showed diffuse positivity for both the S100 and SOX10 proteins . It was concluded that the tumor was a benign diaphragmatic schwannnoma.\nThere were no postoperative complications. The patient was discharged on the fifth postoperative day and is doing well 4 months after the surgery.", + "fulltext_subclaims": [ + "The patient was a 77-year-old woman.", + "She was referred to the department after requesting surgical treatment for a tumor near the gastric fornix.", + "She had a preventive esophagogastroduodenoscopy 2 years and 7 months before referral.", + "The examination had revealed a submucosal tumor-like lesion in the fornix, measuring 10 mm.", + "Contrast enhanced computed tomography revealed a low density, round mass measuring approximately 20 mm located between the upper stomach and left lateral segment of the liver.", + "Magnetic resonance imaging revealed that the mass showed a high signal intensity on T2-weighted imaging.", + "The MRI suggested the mass seemed to be distinct from the stomach.", + "A follow-up MRI performed 5 months later showed slight growth of the tumor.", + "Endoscopic ultrasonography revealed a cystic structure continuous with the gastric wall.", + "The EUS results suggested that a gastrointestinal stromal tumor could not be ruled out.", + "The patient was referred to the endoscopy division of the hospital two years ago.", + "On admission, she had no abnormal symptoms such as fever, anemia, or jaundice.", + "Her performance status was good (Eastern Cooperative Oncology Group score of 0).", + "She had a history of Sjögren syndrome.", + "She had no history of diabetes or hypertension.", + "She had no history of smoking or alcohol abuse.", + "She had no family history of malignant diseases.", + "Laboratory studies were within normal range.", + "The EUS was re-examined and concluded that the cystic tumor with solid components did not originate from either the liver or the stomach.", + "Fine-needle aspiration biopsy was not performed.", + "According to Japanese Clinical Practice Guidelines for GIST, 3rd edition, it is contraindicated to perform EUS-FNA for extramurally grown submucosal tumor.", + "The differential diagnoses considered were bronchogenic cyst, epidermoid cyst, lymph node with cystic degeneration, and neurogenic tumor.", + "Regular follow-ups were recommended for the patient.", + "A follow-up EUS performed 1 year and 6 months after admission revealed the cystic tumor had grown to 25 mm in diameter.", + "The CT scan showed an unclear part of the boundary between the tumor and the gastric wall.", + "The possibility of GIST could not be completely excluded.", + "The patient requested surgical resection.", + "The tumor was rather small (less than 3 cm in diameter).", + "A laparoscopic approach was decided for resection.", + "The tumor was located close to the upper stomach.", + "The brunt port was inserted from the umbilicus.", + "A 12 mm trocar and three 5 mm trocars were placed in the reverse trapezoid position in the upper abdomen.", + "The Nathanson’s retractor was placed in the epigastrium as the liver retractor.", + "An initial laparoscopic examination revealed a firm, completely encapsulated mass located on the left of the diaphragm.", + "Partial diaphragmectomy with complete inclusion of the tumor was performed using laparoscopic coagulation shears.", + "The tumor was packed in a plastic bag and extracted via the umbilical incision.", + "The defect of the diaphragm was directly closed by a running suture using the 3-0 V-Loc™ absorbable suture.", + "The total operating time was 59 min.", + "The intraoperative blood loss was negligible.", + "The tumor measured 2.5 × 2.0 × 1.8 cm and was well encapsulated.", + "The cut section of the tumor showed a tan or yellow solid component and cystic abnormalities.", + "The tumor was surrounded by a pink fibrous capsule with a cystic area.", + "The tumor showed a pattern of alternating highly cellular Antoni type A and less cellular Antoni type B areas.", + "The tumor was composed of spindle cells with bland, twisted nuclei and indistinct cytoplasmic border arranged in short bundles or interlacing fascicles.", + "In the Antoni type A area, the spindle cells showed nuclear palisading.", + "The tumor cells showed diffuse positivity for both the S100 and SOX10 proteins.", + "It was concluded that the tumor was a benign diaphragmatic schwannoma.", + "There were no postoperative complications.", + "The patient was discharged on the fifth postoperative day.", + "The patient is doing well 4 months after the surgery." + ], + "summary": "A 77-year-old woman was referred to our department for surgical treatment of a tumor located near the gastric fornix. She underwent a routine esophagogastroduodenoscopy 2 years and 7 months prior to the referral. It was suspected that she had a submucosal tumor measuring 10 mm, located in the fornix, and was then referred to her previous physician. During her follow-up, endoscopic ultrasonography (EUS) revealed that the cystic structure had continued to grow toward the gastric wall, and she was then referred to the endoscopy division of our hospital. She continued to be followed-up, and it was noted that the tumor was gradually increasing in size. Therefore, she requested surgical resection, and was finally referred to our division. Since the tumor was rather small, we planned a laparoscopic surgery. An initial examination during the operation revealed that the tumor was located on the left diaphragm. Since the tumor was relatively small and visibility was good, we decided to continue with the laparoscopic surgery. Partial diaphragmectomy with complete inclusion of the tumor was performed, and the defect of the diaphragm was directly closed by a running suture. Pathological examination revealed a benign schwannoma that had originated from the diaphragm. To support our findings, we also reviewed the scientific literature on diaphragmatic schwannoma cases reported up to April 2020.", + "summary_subclaims": [ + "A 77-year-old woman was referred to our department for surgical treatment of a tumor located near the gastric fornix.", + "She underwent a routine esophagogastroduodenoscopy 2 years and 7 months prior to the referral.", + "It was suspected that she had a submucosal tumor measuring 10 mm, located in the fornix.", + "During her follow-up, endoscopic ultrasonography revealed that the cystic structure had continued to grow toward the gastric wall.", + "She was referred to the endoscopy division of our hospital.", + "It was noted that the tumor was gradually increasing in size.", + "She requested surgical resection.", + "Since the tumor was rather small, we planned a laparoscopic surgery.", + "An initial examination during the operation revealed that the tumor was located on the left diaphragm.", + "We decided to continue with the laparoscopic surgery.", + "Partial diaphragmectomy with complete inclusion of the tumor was performed.", + "The defect of the diaphragm was directly closed by a running suture.", + "Pathological examination revealed a benign schwannoma that had originated from the diaphragm.", + "We also reviewed the scientific literature on diaphragmatic schwannoma cases reported up to April 2020." + ] + }, + { + "id": "multiclinsum_test_2164_en.txt", + "fulltext": "A 29-year-old female, gravida 3 para 2 at 29 weeks gestation presented to the emergency department (ED) with left arm and neck swelling. Her pregnancy had been complicated by hyperemesis gravidarum requiring a left-sided PICC. Her medical history was significant for prior pregnancies complicated by hyperemesis and a reported history of opoid use disorder on buprenorphine. The PICC had been removed at another ED approximately three days prior to presentation at our ED after the site had become erythematous and painful. She was placed on oral antibiotics and recommended to follow up with her obstetrician. Despite removal of the the PICC, the site had become severely swollen and erythematous extending over her left neck. In addition, she had begun to experience chest pain, worsening shortness of breath, fever, chills, and left arm paresthesias, which prompted her to seek evaluation.\nOn arrival her heart rate (HR) was in the 160s beats per minute (bpm) and blood pressure (BP) 95/67 millimeters of mercury (mm Hg); otherwise, her vital signs were within normal limits. On physical exam, the PICC site was erythematous, swollen, and tender. She had marked swelling involving her left upper extremity, chest, and left side of the neck. Given the patient’s vitals and physical exam, there was significant clinical suspicion for deep venous thrombosis (DVT). We used point-of-care-ultrasound to perform a bedside DVT assessment with noted extensive clot burden extending through the basilic vein into the axillary vein , as well as in the IJ vein . Serum labs were notable for a white blood count of 20.7 × 103 cells per microliter (uL) with 80% neutrophils (reference range: 3.7–11 ×103 cells/uL).\nThe findings prompted a recommendation that she undergo a computed tomography (CT) pulmonary embolism protocol, which she consented to. Cross-sectional imaging demonstrated extensive clot burden encompassing the left brachiocephalic, left subclavian, and left internal and external jugular veins . The CT was also concerning for septic pulmonary emboli. Given the combination of extensive clot burden encompassing the IJ, in addition to septic emboli, we were able to confirm the diagnosis of Lemierre’s syndrome. The patient was immediately initiated on heparin and broad-spectrum antibiotics.\nObstetrics was consulted at the time of the patient’s arrival and was bedside shortly thereafter. She received dexamethasone six milligrams intramuscular in the event of an emergent cesarean section. Fortunately, neonatal stress testing demonstrated no evidence of fetal distress, and the patient continued to improve. She was subsequently admitted to the intensive care unit (ICU) by which time her HR had improved to 116 bpm and BP to 105/52 mm Hg. Interventional radiology was also consulted for possible thrombectomy vs thrombolysis at time of arrival; however, given the patient’s improvement by time of admission to the ICU the recommendation was for conservative therapy. While inpatient, blood cultures resulted positive for methicillin-sensitive Staphylococcus aureus (MSSA).\nUltimately the patient did very well without requiring procedural intervention or cesarean section. She was continued on enoxaparin and discharged on six weeks of cefazolin.", + "fulltext_subclaims": [ + "The patient is a 29-year-old female, gravida 3 para 2 at 29 weeks gestation.", + "She presented to the emergency department with left arm and neck swelling.", + "Her pregnancy had been complicated by hyperemesis gravidarum requiring a left-sided PICC.", + "The PICC had been removed at another ED approximately three days prior to presentation at our ED.", + "The PICC site had become erythematous and painful.", + "She was placed on oral antibiotics and recommended to follow up with her obstetrician.", + "The PICC site had become severely swollen and erythematous extending over her left neck.", + "She had begun to experience chest pain, worsening shortness of breath, fever, chills, and left arm paresthesias.", + "On arrival, her heart rate was in the 160s beats per minute.", + "On arrival, her blood pressure was 95/67 millimeters of mercury.", + "On physical exam, the PICC site was erythematous, swollen, and tender.", + "She had marked swelling involving her left upper extremity, chest, and left side of the neck.", + "There was significant clinical suspicion for deep venous thrombosis.", + "A bedside DVT assessment with point-of-care-ultrasound was performed.", + "The ultrasound showed extensive clot burden extending through the basilic vein into the axillary vein.", + "The ultrasound showed clot burden in the IJ vein.", + "Serum labs were notable for a white blood count of 20.7 × 103 cells per microliter.", + "Serum labs showed 80% neutrophils.", + "The patient underwent a computed tomography pulmonary embolism protocol.", + "Cross-sectional imaging demonstrated extensive clot burden encompassing the left brachiocephalic, left subclavian, and left internal and external jugular veins.", + "The CT was also concerning for septic pulmonary emboli.", + "The diagnosis of Lemierre’s syndrome was confirmed.", + "The patient was immediately initiated on heparin.", + "The patient was immediately started on broad-spectrum antibiotics.", + "Obstetrics was consulted at the time of the patient’s arrival.", + "The patient received dexamethasone six milligrams intramuscular.", + "Neonatal stress testing demonstrated no evidence of fetal distress.", + "The patient was admitted to the intensive care unit.", + "By time of admission to the ICU, her heart rate had improved to 116 bpm.", + "By time of admission to the ICU, her blood pressure had improved to 105/52 mm Hg.", + "Interventional radiology was consulted for possible thrombectomy vs thrombolysis.", + "Given the patient’s improvement by time of admission to the ICU, the recommendation was for conservative therapy.", + "Blood cultures resulted positive for methicillin-sensitive Staphylococcus aureus.", + "The patient did very well without requiring procedural intervention or cesarean section.", + "The patient was continued on enoxaparin.", + "The patient was discharged on six weeks of cefazolin." + ], + "summary": "We detail a case of Lemierre's syndrome resulting from a peripherally inserted central catheter in a pregnant female patient. Diagnosis of this rare and potentially life-threatening disease process was expedited using point-of-care ultrasound.", + "summary_subclaims": [ + "We detail a case of Lemierre's syndrome.", + "The Lemierre's syndrome resulted from a peripherally inserted central catheter.", + "The patient was a pregnant female.", + "Diagnosis was expedited using point-of-care ultrasound." + ] + }, + { + "id": "multiclinsum_test_1615_en.txt", + "fulltext": "A 10-year-old girl was referred to the pediatric orthopedic clinic with a right foot deformity which had started at age 4 and had slowly progressed. The parents were certain that the child had symmetric feet shape from birth. There was no history of a similar deformity in the close or distant family members. There was no family history of any neuromuscular disorder.\nThe physical examination revealed plantigrade feet, with a distinctly right flatfoot with a well-formed longitudinal arch on the left side . There was no evidence of spine anomaly, peripheral neuropathy or myopathy. The right foot examination showed intact sensation, and full power in all the muscles, except for the inversion power which was weaker than the opposite foot. On closer inspection of the foot, a small scar of about 3-4 mm was visible just posterior to the medial malleolus. On further questioning of the parents, they remembered their daughter having cut herself on a piece of rock playing in a park at age 3. This did not require any medical attention and apparently healed uneventfully in few days. This piece of history led to the further investigation including a magnetic resonance imaging of the leg which showed the absence of TPT at the ankle level, and atrophic muscle.\nSurgery, through a slightly curved medial foot and ankle incision, showed a fibrous stump of old TPT on the navicular tip. There was no evidence of TPT. The atrophic muscle was, however, found some 12 cm proximal to the medial malleolus with no visible tendon end.\nA reconstruction with the flexor hallucis longus longus (FHL) tendon was planned. The incision was extended distally, the “Master Knot of Henry” - the fibrous slip that envelope the FHL and the flexor digitorum (FDL) tendons - was exposed. The FHL was cut at that level, and proximal end was transferred to the navicular bone and tightly sutured to bone and remnants of TPT. The distal stump of the FHL was tightly sutured to the FDL ( and ). Following 6 weeks of cast immobilization a course of physiotherapy was started .\nThe longitudinal arch was restored and has remained nicely intact up to the last visit 3 years post-surgery . The patient has a pain-free motion of foot, ankle, and toes, and is satisfied. The push off is strong, and she shows very nice longitudinal arch when standing on tiptoes. She could do repeated push off exercise on tiptoes with similar power and foot-arch shape as the opposite foot, without any fatigue.", + "fulltext_subclaims": [ + "The patient is a 10-year-old girl.", + "She was referred to the pediatric orthopedic clinic with a right foot deformity.", + "The right foot deformity had started at age 4.", + "The parents were certain that the child had symmetric feet shape from birth.", + "There was no history of a similar deformity in the close or distant family members.", + "There was no family history of any neuromuscular disorder.", + "The physical examination revealed plantigrade feet.", + "There was a distinctly right flatfoot with a well-formed longitudinal arch on the left side.", + "There was no evidence of spine anomaly.", + "There was no evidence of peripheral neuropathy.", + "There was no evidence of myopathy.", + "The right foot examination showed intact sensation.", + "The right foot examination showed full power in all the muscles, except for the inversion power which was weaker than the opposite foot.", + "A small scar of about 3-4 mm was visible just posterior to the medial malleolus.", + "The parents remembered their daughter having cut herself on a piece of rock playing in a park at age 3.", + "This did not require any medical attention.", + "This apparently healed uneventfully in few days.", + "A magnetic resonance imaging of the leg showed the absence of TPT at the ankle level.", + "A magnetic resonance imaging of the leg showed atrophic muscle.", + "Surgery showed a fibrous stump of old TPT on the navicular tip.", + "There was no evidence of TPT.", + "The atrophic muscle was found some 12 cm proximal to the medial malleolus with no visible tendon end.", + "A reconstruction with the flexor hallucis longus longus (FHL) tendon was planned.", + "The incision was extended distally.", + "The “Master Knot of Henry” was exposed.", + "The FHL was cut at that level.", + "The proximal end of the FHL was transferred to the navicular bone.", + "The proximal end of the FHL was tightly sutured to bone and remnants of TPT.", + "The distal stump of the FHL was tightly sutured to the FDL.", + "Following 6 weeks of cast immobilization, a course of physiotherapy was started.", + "The longitudinal arch was restored and has remained nicely intact up to the last visit 3 years post-surgery.", + "The patient has a pain-free motion of foot, ankle, and toes.", + "The patient is satisfied.", + "The push off is strong.", + "She shows very nice longitudinal arch when standing on tiptoes.", + "She could do repeated push off exercise on tiptoes with similar power and foot-arch shape as the opposite foot.", + "She could do repeated push off exercise on tiptoes without any fatigue." + ], + "summary": "A 10-year-old girl presented with unilateral flatfoot and unusual shoe wear of few years duration. A TPT rupture was diagnosed. After observing a 3-4 mm superficial scar behind medial malleolus, and after a lot of questioning, her mother remembered an abrasion she had sustained 6 years ago playing in a park.She was successfully treated by flexor hallucis longus (FHL) tendon transfer and obtained and maintained a nice longitudinal arch.", + "summary_subclaims": [ + "A 10-year-old girl presented with unilateral flatfoot.", + "She had unusual shoe wear of few years duration.", + "A TPT rupture was diagnosed.", + "A 3-4 mm superficial scar behind medial malleolus was observed.", + "Her mother remembered an abrasion she had sustained 6 years ago playing in a park.", + "She was successfully treated by flexor hallucis longus (FHL) tendon transfer.", + "She obtained and maintained a nice longitudinal arch." + ] + }, + { + "id": "multiclinsum_test_88_en.txt", + "fulltext": "18-year-old Indonesian woman, presenting with a complex medical history and challenging diagnostic journey. Initially presenting with a painful lesion on the right palm, which developed following a traumatic injury and exhibited characteristics such as reddish swelling, well-defined borders, contractures of the middle finger, and discharge of purulent material, the patient's condition did not align with typical diagnoses of cellulitis or chronic osteomyelitis based on her history and clinical findings .\nThe absence of common predisposing factors for cellulitis, alongside negative indicators for chronic osteomyelitis such as fistulous tracts, acute musculoskeletal pain, or constitutional symptoms, prompted further investigation. The clinical examination revealed an erythematous, edematous scaly plaque on the right palm, with features not entirely consistent with the initially considered differential diagnoses.\nThe diagnostic process included routine investigations, chest X-ray, and specific imaging of the right palm , alongside a positive tuberculin skin test indicating TB exposure. From the anamnesis, no history of TB exposure was found in the home or school environment. Surgical intervention comprising necrotomy, debridement, and contracture release, followed by skin flap, was undertaken . Histopathological examination of the biopsy revealed pseudoepitheliomatous hyperplasia and non-caseating granulomas, leading to a diagnosis of CTB, potentially lupus vulgaris (LV) or tuberculosis verrucosa cutis (TVC).\nThe patient's subsequent improvement under multidrug TB therapy, consistent with WHO recommendations for our country using a Fixed Drug Combination (FDC) of 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol, underscores the importance of considering CTB in the differential diagnosis of persistent, non-healing cutaneous lesions. This is especially critical in endemic regions or in patients with a history suggestive of TB exposure. A month after surgery and TB therapy, the wound went well .", + "fulltext_subclaims": [ + "The patient is an 18-year-old Indonesian woman.", + "She presented with a painful lesion on the right palm.", + "The lesion developed following a traumatic injury.", + "The lesion exhibited reddish swelling.", + "The lesion had well-defined borders.", + "The lesion had contractures of the middle finger.", + "The lesion had discharge of purulent material.", + "The condition did not align with typical diagnoses of cellulitis.", + "The condition did not align with typical diagnoses of chronic osteomyelitis.", + "The absence of common predisposing factors for cellulitis was noted.", + "Negative indicators for chronic osteomyelitis included no fistulous tracts.", + "Negative indicators for chronic osteomyelitis included no acute musculoskeletal pain.", + "Negative indicators for chronic osteomyelitis included no constitutional symptoms.", + "The clinical examination revealed an erythematous, edematous scaly plaque on the right palm.", + "The features were not entirely consistent with the initially considered differential diagnoses.", + "Routine investigations were performed.", + "A chest X-ray was performed.", + "Specific imaging of the right palm was performed.", + "A positive tuberculin skin test indicated TB exposure.", + "No history of TB exposure was found in the home or school environment.", + "Surgical intervention comprising necrotomy, debridement, and contracture release was undertaken.", + "A skin flap was performed.", + "Histopathological examination of the biopsy revealed pseudoepitheliomatous hyperplasia.", + "Histopathological examination of the biopsy revealed non-caseating granulomas.", + "The diagnosis was CTB, potentially lupus vulgaris (LV) or tuberculosis verrucosa cutis (TVC).", + "The patient received multidrug TB therapy.", + "The therapy was consistent with WHO recommendations.", + "The therapy used a Fixed Drug Combination (FDC) of 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol.", + "The wound went well a month after surgery and TB therapy." + ], + "summary": "An 18-year-old patient presented with a painful, well-defined reddish plaque on the right palm, originating five years prior, accompanied by contractures of the middle finger. The tender lesion, characterized by an irregular surface, exhibited purulent discharge upon light touch through fissures along its periphery. Management involved necrotomy, debridement, and tissue biopsy for diagnostic and reconstructive purposes.", + "summary_subclaims": [ + "The patient is an 18-year-old.", + "The patient had a painful, well-defined reddish plaque on the right palm.", + "The plaque originated five years prior to presentation.", + "The lesion was accompanied by contractures of the middle finger.", + "The tender lesion had an irregular surface.", + "The lesion exhibited purulent discharge upon light touch through fissures along its periphery.", + "Management involved necrotomy.", + "Management involved debridement.", + "Tissue biopsy was performed for diagnostic and reconstructive purposes." + ] + }, + { + "id": "multiclinsum_test_1068_en.txt", + "fulltext": "A 69-year-old woman developed a sudden drooping on the left side of the face while having dinner with her family. Her daughter noticed slurred speech and alerted emergency medical services immediately. The patient was pre-announced to the stroke service by the responding emergency medical technician and immediately admitted to the emergency room. Her home medication consisted of pantoprazole only. Upon admission to the emergency room, the patient was alert but slightly confused. Further neurological examination revealed a left-sided hemiparesis and motor speech disorder. The remaining cranial nerves were unaffected. No sensory or coordinative dysfunctions were detected. Muscle stretch reflexes revealed no lateral differences, and plantar reflexes were normal (NIHSS score: 4 points). Shaved hair over the right temple exposed a well-healing, 10-cm-long recent wound. The patient reported having had brain surgery two weeks earlier, but upon further questioning denied a preceding trauma, infection, tumor disease, or cerebral bleeding.\nThe non-contrast computed tomography (CT) imaging revealed hypodense areas in the circulation of the middle cerebral artery (MCA) with territorial pattern (mainly pre-Rolandic, but also Rolandic, parietal, and insular branches), moderate swelling, and hemorrhagic transformation of the anterior portion (see Fig. ). A vascular clip in projection on the middle cerebral artery was visible. There was no sign of a subarachnoid hemorrhage (SAH). The CT-angiography revealed no high-grade stenosis or vessel occlusion of the cerebral blood flow in the area of the right middle cerebral artery, even though the presence of a vascular clip reduced reliability of assessment. The cerebral duplex ultrasonography/transcranial Doppler sonography (TCD) showed, in contrast to the left side, markedly increased blood flow velocities in the right MCA with mean values up to 180 cm/s (Vmax up to 300 cm/s), while the blood flow in all of the other cerebral arteries was undisturbed. The increased velocities were traceable along the entire M1 segment as well as in the M2 segments of the right MCA. In contrast to the preoperative transfemoral catheter angiography (TFCA), the subsequent right internal carotid angiogram showed clear signs of vasospasm along the M1 and M2 segments of the right MCA (see Fig. ). However, neither delayed cerebral blood flow nor hypoperfusion were found. A vessel narrowing with consecutive stenosis due to a suboptimally placed clip was ruled out.\nThe patient’s recent medical history included the microsurgical treatment of a right-sided MCA aneurysm 12 days prior. The patient had never experienced any episodes of uncommon or severe headaches. The unruptured intracranial aneurysm (UIA) was found incidentally via magnetic resonance imaging ordered after the patient complained of a short period of slight gait disturbances. To avoid an SAH and consecutive complications like vasospasms, the patient elected surgical treatment (see Fig. ). Endovascular management was not feasible due to the configuration of the aneurysm. The review of the operative report and the medical discharge letter attested to an uneventful perioperative course. Clipping was managed by keyhole approach. A craniotomy 30 mm in diameter was performed over the right Sylvian fissure. The aneurysm was dissected after securing proximal control of the distal M1 segment of the right MCA. Temporal clipping of the M1 was not necessary. After clip placement, appropriate flow in all distal segments was confirmed by indocyanine green video-angiography and micro-Doppler. The postoperative imaging showed no sign of decreased cerebral blood flow. The patient was discharged seven days after surgery without neurological deficits. No other vascular diseases were known.\nAfter admission antithrombotic treatment with acetylsalicylic acid was begun. In accordance with guidelines for the treatment of subarachnoid hemorrhage and vasospasm, nimodipine was added. Periodically performed transcranial duplex sonography showed a further increase of blood flow velocity in the MCA and its branches for four days before a continuous decrease and normalization of flow velocity was observed. Treatment with nimodipine was continued for an additional two weeks. Within this time the symptoms disappeared completely. The patient made a full recovery, which is remarkable in such a major stroke. After 11 days the woman was discharged with no symptoms.", + "fulltext_subclaims": [ + "The patient is a 69-year-old woman.", + "She developed a sudden drooping on the left side of the face.", + "Her daughter noticed slurred speech.", + "Emergency medical services were alerted immediately.", + "The patient was pre-announced to the stroke service.", + "She was immediately admitted to the emergency room.", + "Her home medication consisted of pantoprazole only.", + "Upon admission, the patient was alert but slightly confused.", + "Neurological examination revealed left-sided hemiparesis.", + "Neurological examination revealed a motor speech disorder.", + "The remaining cranial nerves were unaffected.", + "No sensory or coordinative dysfunctions were detected.", + "Muscle stretch reflexes revealed no lateral differences.", + "Plantar reflexes were normal.", + "The NIHSS score was 4 points.", + "Shaved hair over the right temple exposed a well-healing, 10-cm-long recent wound.", + "The patient reported having had brain surgery two weeks earlier.", + "The patient denied a preceding trauma.", + "The patient denied a preceding infection.", + "The patient denied tumor disease.", + "The patient denied cerebral bleeding.", + "Non-contrast CT imaging revealed hypodense areas in the MCA circulation.", + "The hypodense areas showed a territorial pattern.", + "The hypodense areas were mainly pre-Rolandic.", + "The hypodense areas also involved Rolandic, parietal, and insular branches.", + "Moderate swelling was observed.", + "Hemorrhagic transformation of the anterior portion was noted.", + "A vascular clip in projection on the MCA was visible.", + "There was no sign of subarachnoid hemorrhage.", + "CT-angiography revealed no high-grade stenosis.", + "CT-angiography revealed no vessel occlusion.", + "The presence of a vascular clip reduced the reliability of assessment.", + "Cerebral duplex ultrasonography showed increased blood flow velocities in the right MCA.", + "Mean blood flow velocities in the right MCA were up to 180 cm/s.", + "Vmax in the right MCA was up to 300 cm/s.", + "Blood flow in all other cerebral arteries was undisturbed.", + "The increased velocities were traceable along the entire M1 segment.", + "The increased velocities were also traceable in the M2 segments.", + "Right internal carotid angiogram showed signs of vasospasm.", + "Vasospasm was along the M1 and M2 segments.", + "No delayed cerebral blood flow was found.", + "No hypoperfusion was found.", + "A vessel narrowing with consecutive stenosis due to a suboptimally placed clip was ruled out.", + "The patient had microsurgical treatment of a right-sided MCA aneurysm 12 days prior.", + "The patient had never experienced episodes of uncommon or severe headaches.", + "The unruptured intracranial aneurysm was found incidentally via MRI.", + "MRI was ordered after the patient complained of a short period of slight gait disturbances.", + "Surgical treatment was elected to avoid SAH.", + "Endovascular management was not feasible.", + "The review of the operative report attested to an uneventful perioperative course.", + "Clipping was managed by keyhole approach.", + "A craniotomy 30 mm in diameter was performed over the right Sylvian fissure.", + "The aneurysm was dissected after securing proximal control of the distal M1 segment.", + "Temporal clipping of the M1 was not necessary.", + "Appropriate flow in all distal segments was confirmed by indocyanine green video-angiography.", + "Appropriate flow in all distal segments was confirmed by micro-Doppler.", + "Postoperative imaging showed no sign of decreased cerebral blood flow.", + "The patient was discharged seven days after surgery without neurological deficits.", + "No other vascular diseases were known.", + "Antithrombotic treatment with acetylsalicylic acid was begun.", + "Nimodipine was added in accordance with guidelines.", + "Transcranial duplex sonography showed a further increase of blood flow velocity for four days.", + "A continuous decrease and normalization of flow velocity was observed.", + "Treatment with nimodipine was continued for an additional two weeks.", + "Symptoms disappeared completely.", + "The patient made a full recovery.", + "The patient was discharged after 11 days with no symptoms." + ], + "summary": "We present a case of a 69-year-old woman who suffered from vasospasm and delayed cerebral ischemia that occurred after an uneventful clipping of a UIA. The aneurysm of the right middle cerebral artery was found incidentally via magnetic resonance imaging ordered after the patient complained of a short period of slight gait disturbances. To avoid a subarachnoid hemorrhage and consecutive complications like vasospasms, the patient elected microsurgical treatment. Clipping was managed by keyhole approach. Temporal clipping of the M1 was not necessary. After clip placement, appropriate flow in all distal segments was confirmed by indocyanine green video-angiography and micro-Doppler. The patient was discharged seven days after surgery without neurological deficits. After 12 days, the patient developed at home a sudden drooping on the left side of the face. Upon admission to the emergency room, the patient was alert but slightly confused. Neurological examination revealed a left-sided hemiparesis and motor speech disorder. In contrast to the preoperative transfemoral catheter angiography, the subsequent right internal carotid angiogram showed clear signs of vasospasm along the M1 and M2 segments of the right middle cerebral artery. Antithrombotic treatment with acetylsalicylic acid was begun. In accordance with guidelines for the treatment of subarachnoid hemorrhage and vasospasm, nimodipine was added. After 11 days the patient was discharged with no symptoms.", + "summary_subclaims": [ + "The patient was a 69-year-old woman.", + "The patient suffered from vasospasm and delayed cerebral ischemia.", + "The vasospasm and delayed cerebral ischemia occurred after an uneventful clipping of a UIA.", + "The aneurysm of the right middle cerebral artery was found incidentally via magnetic resonance imaging.", + "The magnetic resonance imaging was ordered after the patient complained of a short period of slight gait disturbances.", + "The patient elected microsurgical treatment to avoid a subarachnoid hemorrhage.", + "The patient elected microsurgical treatment to avoid consecutive complications like vasospasms.", + "Clipping was managed by keyhole approach.", + "Temporal clipping of the M1 was not necessary.", + "Appropriate flow in all distal segments was confirmed by indocyanine green video-angiography.", + "Appropriate flow in all distal segments was confirmed by micro-Doppler.", + "The patient was discharged seven days after surgery without neurological deficits.", + "After 12 days, the patient developed at home a sudden drooping on the left side of the face.", + "Upon admission to the emergency room, the patient was alert but slightly confused.", + "Neurological examination revealed a left-sided hemiparesis.", + "Neurological examination revealed a motor speech disorder.", + "The subsequent right internal carotid angiogram showed clear signs of vasospasm along the M1 and M2 segments of the right middle cerebral artery.", + "Antithrombotic treatment with acetylsalicylic acid was begun.", + "Nimodipine was added in accordance with guidelines for the treatment of subarachnoid hemorrhage and vasospasm.", + "After 11 days the patient was discharged with no symptoms." + ] + }, + { + "id": "multiclinsum_test_2088_en.txt", + "fulltext": "A 21-year-old male was referred to our hospital due to worsening pain in his right shoulder. He denied any history of trauma or excessive load-bearing activities, and there was no family history of cancer. During the physical examination, we observed a deformity in his right shoulder, which appeared asymmetrical compared to the left side, and he experienced pain upon palpation of the distal third of the clavicle. Plain radiographs revealed an osteolytic lesion with cortical thinning in the distal third of the clavicle, while axial and sagittal views of the MRI showed tumor growth on the lateral third of the right clavicle with contrast enhancement (a-c). Before surgery, Multislice-Computed Tomography (MSCT) scans of the abdomen, and thorax, and a complete bone survey were conducted, revealing no additional masses in other regions. Based on the clinical and radiological results, we suspected a primary benign bone lesion with a Bone RADS score of 1, in accordance with the guidelines of the American College of Radiology. We planned for an open biopsy along with curettage and internal fixation of the clavicle which was performed three days later.\nDuring the surgery, we used the anterior clavicle approach to remove the tumor. We confirmed that there was no fracture. The tumor was sent for diagnosis and the cavity left was filled with bone graft and fixed with a 6-hole plate with a locking mechanism .\nMicroscopic examination revealed bone tissue with diffuse tumor cells, of moderate size, with eosinophilic cytoplasm. Some cells exhibited oval nuclei, some eccentric, some showing grooves. Among them were numerous eosinophils and lymphocytes, as well as multinucleated osteoclastic giant cells. We proceeded with Immunohistochemistry staining, which yielded positive results for CD1a (+) and negative results for LCA (CD45) (−), CD30 (−), and CD138 (−). Therefore, based on these findings, a diagnosis of Langerhans cell histiocytosis was concluded .\nWe brought our patient's findings along with our treatment result for clinicopathologic conference with multidisciplinary team, which all agreed on LCH to be the diagnosis. On his nine-month follow-up, no tumor-progressive changes were seen on examination nor complained by the patient . However, the callous formation has been minimal which concerned us for potentially impaired bone healing. The patient has then received radiotherapy and his latest MRI only showed no residual mass and excellent clavicle alignment.", + "fulltext_subclaims": [ + "The patient is a 21-year-old male.", + "He was referred to the hospital due to worsening pain in his right shoulder.", + "He denied any history of trauma.", + "He denied any history of excessive load-bearing activities.", + "There was no family history of cancer.", + "Physical examination showed a deformity in the right shoulder.", + "The right shoulder appeared asymmetrical compared to the left side.", + "He experienced pain upon palpation of the distal third of the clavicle.", + "Plain radiographs revealed an osteolytic lesion with cortical thinning in the distal third of the clavicle.", + "MRI showed tumor growth on the lateral third of the right clavicle.", + "MRI showed contrast enhancement.", + "MSCT scans of the abdomen, thorax, and a complete bone survey were conducted.", + "No additional masses were found in other regions.", + "A primary benign bone lesion was suspected.", + "The Bone RADS score was 1.", + "An open biopsy was planned.", + "Curettage and internal fixation of the clavicle were planned.", + "The surgery was performed three days later.", + "The anterior clavicle approach was used to remove the tumor.", + "No fracture was confirmed.", + "The tumor was sent for diagnosis.", + "The cavity was filled with bone graft.", + "The cavity was fixed with a 6-hole plate with a locking mechanism.", + "Microscopic examination revealed bone tissue with diffuse tumor cells.", + "The tumor cells were of moderate size with eosinophilic cytoplasm.", + "Some cells exhibited oval nuclei.", + "Some cells showed eccentric nuclei.", + "Some cells showed grooves.", + "Numerous eosinophils were present.", + "Numerous lymphocytes were present.", + "Multinucleated osteoclastic giant cells were present.", + "Immunohistochemistry staining was positive for CD1a.", + "Immunohistochemistry staining was negative for LCA (CD45).", + "Immunohistochemistry staining was negative for CD30.", + "Immunohistochemistry staining was negative for CD138.", + "A diagnosis of Langerhans cell histiocytosis was concluded.", + "A clinicopathologic conference with a multidisciplinary team agreed on LCH as the diagnosis.", + "On nine-month follow-up, no tumor-progressive changes were seen.", + "Callous formation has been minimal.", + "The patient received radiotherapy.", + "The latest MRI showed no residual mass.", + "The latest MRI showed excellent clavicle alignment." + ], + "summary": "A 21-year-old male was referred to our hospital due to pain in his right shoulder. Plain radiograph and MRI showed a solitary well-marginated lytic lesion on the distal third of the clavicle. Together with a clear history and physical exam, the benign bone cyst was suspected and we performed an open biopsy simultaneously with curettage followed by internal fixation using a bone graft. Pathology and immunohistochemistry dismissed our suspicion and confirmed LCH as the main diagnosis. At six months post-surgery, no signs of recurrence were seen on the fixated site nor complained by the patient.", + "summary_subclaims": [ + "A 21-year-old male was referred to our hospital due to pain in his right shoulder.", + "Plain radiograph and MRI showed a solitary well-marginated lytic lesion on the distal third of the clavicle.", + "The benign bone cyst was suspected.", + "An open biopsy was performed simultaneously with curettage.", + "Internal fixation using a bone graft was performed.", + "Pathology and immunohistochemistry dismissed the suspicion of a benign bone cyst.", + "Pathology and immunohistochemistry confirmed LCH as the main diagnosis.", + "At six months post-surgery, no signs of recurrence were seen on the fixated site.", + "At six months post-surgery, no signs of recurrence were complained by the patient." + ] + }, + { + "id": "multiclinsum_test_2181_en.txt", + "fulltext": "A 23-year-old female presented to our hospital with bilateral congenital malformed thumbs. The patient had understood her condition since she was a child and refused to undergo surgical correction. In adulthood, the patient encountered two main problems. First, she usually felt unconfident due to the cosmetic appearance of her thumbs. Second, those thumbs disturbed her activities when precise movements were needed, such as sewing. This activity, sewing, is essential for her job as a tailor. As time went on, the patient felt more uncomfortable with her thumbs since they made sewing difficult. Finally, the patient and her parents sought medical advice for her thumbs.\nPhysical examination showed that the left thumb deviated 25° to the ulnar side, while the contralateral thumb deviated 15° to the radial side without any swelling in either thumb . There was no sign of pain or inflammation in either thumb. Both thumbs also did not suffer from limited movement in abduction and flexion. Other than the malformation, there was no medical condition such as anemia or a history of trauma. The Disability of Arm, Shoulder, and Hand (DASH) score was evaluated to assess the specific disability of the extremity, and the result was 17.5. The Sollerman Hand Function (SHF) and Michigan Hand Outcome were also evaluated, giving scores of 56 and 60 for the left and right hand on the SHF test, and 65.6 and 66.6 for the left and right hand on the Michigan Hand Outcome.\nUnder the plain x-ray of the thumb , it was revealed that both thumbs had an extra delta-shaped bone between two normal bones at the distal interphalangeal (DIP) joint. Hence, the patient was diagnosed with bilateral delta-type TPT.\nThe patient underwent operation for the correction of both thumbs. In general anesthesia, an H-shaped incision was made on the dorsal side. To expose the accessory phalanx, the extensor tendon was split longitudinally from the PIP joint through the DIP joint. Then, the accessory phalanx was removed, followed by ligament and tendon reconstruction.\nThe distal phalanx and the proximal phalanx were placed close together with denudation of the articular surface. The first K-wire was introduced retrogradely to the distal phalanx intramedullary with the joint flexed to gain an optimal view, then with an antegrade fashion, advanced the K-wire to the proximal phalanx. After the IP joint was in adequate contact, the IP joint was bent in a 10°–15° flexion position. The first K-wire was the primary fixator for longitudinal alignment. Then, the second K-wire was introduced obliquely over the IP joint. The second K-wire acted as an antirotation wire to stabilize the joint . After 3 days of observation, there were no complications.\nSix months later, during the follow-up, the K-wire was removed . There were no chief complaints or adverse events before or after the K-wire removal. To examine the function of the hand after the correctional surgery, the SHF test was executed. The patient also performed tasks with her hands, such as inserting a thread into a pinhole precisely, and returned to work earlier. Both of her hands had a satisfying outcome, with an overall score of 80 and 79 in the dominant and non-dominant hands, respectively. The Michigan Hand Outcome score was 97.2 and 98.9, and the DASH Score was 7.", + "fulltext_subclaims": [ + "The patient is a 23-year-old female.", + "The patient had bilateral congenital malformed thumbs.", + "The patient refused to undergo surgical correction as a child.", + "The patient encountered two main problems in adulthood.", + "The patient usually felt unconfident due to the cosmetic appearance of her thumbs.", + "The thumbs disturbed her activities when precise movements were needed.", + "Sewing is essential for her job as a tailor.", + "The patient felt more uncomfortable with her thumbs as they made sewing difficult.", + "The patient and her parents sought medical advice for her thumbs.", + "The left thumb deviated 25° to the ulnar side.", + "The right thumb deviated 15° to the radial side.", + "There was no swelling in either thumb.", + "There was no sign of pain or inflammation in either thumb.", + "Both thumbs did not suffer from limited movement in abduction and flexion.", + "There was no medical condition such as anemia.", + "There was no history of trauma.", + "The DASH score was 17.5.", + "The SHF scores were 56 for the left hand and 60 for the right hand.", + "The Michigan Hand Outcome scores were 65.6 for the left hand and 66.6 for the right hand.", + "Plain x-ray revealed that both thumbs had an extra delta-shaped bone between two normal bones at the DIP joint.", + "The patient was diagnosed with bilateral delta-type TPT.", + "The patient underwent operation for the correction of both thumbs.", + "An H-shaped incision was made on the dorsal side.", + "The extensor tendon was split longitudinally from the PIP joint through the DIP joint.", + "The accessory phalanx was removed.", + "Ligament and tendon reconstruction was performed.", + "The distal phalanx and the proximal phalanx were placed close together with denudation of the articular surface.", + "The first K-wire was introduced retrogradely to the distal phalanx intramedullary.", + "The first K-wire acted as the primary fixator for longitudinal alignment.", + "The second K-wire was introduced obliquely over the IP joint.", + "The second K-wire acted as an antirotation wire to stabilize the joint.", + "After 3 days of observation, there were no complications.", + "Six months later, during the follow-up, the K-wire was removed.", + "There were no chief complaints or adverse events before or after the K-wire removal.", + "The SHF test was executed to examine the function of the hand after the correctional surgery.", + "The patient performed tasks with her hands, such as inserting a thread into a pinhole precisely.", + "The patient returned to work earlier.", + "Both of her hands had a satisfying outcome.", + "The SHF scores were 80 for the dominant hand and 79 for the non-dominant hand.", + "The Michigan Hand Outcome scores were 97.2 for the left hand and 98.9 for the right hand.", + "The DASH score was 7." + ], + "summary": "A patient with TPT who underwent removal of extra phalanges and arthrodesis of interphalangeal (IP) joints is presented. The left thumb deviated 25o to ulnar while the contralateral part deviated 15o to radial. X-ray revealed both thumbs had extra delta-shaped middle phalanges. Complete excision of extra phalanges and simple arthrodesis of IP joints with two K-wires in 10° to 15° flexion was performed. Healing process ended without any complications and the patient had an improvement.", + "summary_subclaims": [ + "A patient with TPT underwent removal of extra phalanges and arthrodesis of interphalangeal (IP) joints.", + "The left thumb deviated 25o to ulnar.", + "The contralateral part deviated 15o to radial.", + "X-ray revealed both thumbs had extra delta-shaped middle phalanges.", + "Complete excision of extra phalanges was performed.", + "Simple arthrodesis of IP joints with two K-wires in 10° to 15° flexion was performed.", + "The healing process ended without any complications.", + "The patient had an improvement." + ] + }, + { + "id": "multiclinsum_test_2520_en.txt", + "fulltext": "Our patient was a 20-year-old woman with a history of a sacral mass diagnosed by CT-guided needle biopsy 7 years before as benign fibrohistiocytoma. A repeat biopsy of her lesion through an open approach revealed myofibroblastic sarcoma. Consideration was given for reduction of tumor burden and lumbopelvic reconstruction to facilitate long-term progression-free survival and to improve quality of life, respectively.\nThe extension of tumor into both sacroiliac joints prohibited sparing S1; thus, a two-staged total sacrectomy was planned, as previously described. Briefly, the first stage of the procedure included a midline laparotomy, mobilization of the visceral and neural structures, and ligation of the internal iliac vessels. A colostomy was performed, and a right vertical rectus abdominus myocutaneous flap based on the inferior epigastric vessels was mobilized, wrapped in a bowel bag, and placed in the pelvis. The second stage was performed the next day, and it included L5 and S1 laminectomies, bilateral osteotomies and disarticulation of the sacrum from the ilium at the sacroiliac joints, ligation of the thecal sac inferior to the takeoff of the L5 nerve roots, complete L5–S1 discectomy, and transection of the S1–S5 nerve roots. The entire sacrum, along with the tumor, was removed piecemeal. This was followed by lumbopelvic reconstruction with spinal instrumentation and bone graft.\nThe patient underwent a long inpatient postoperative course. She responded well to intensive physical rehabilitation. Her postoperative course was complicated by the development of a small superficial soft tissue Staphylococcus epidermidis abscess in the operative bed treated with percutaneous drainage and a full course of intravenous and oral antibiotics. The patient also developed a small ischial decubitus ulcer, remote from the surgical incision, treated with local wound care. At 3 months after surgery, the patient was able to ambulate with the assistance of a walker. She had normal strength in her left leg, except for plantarflexion (S1). Her right leg was more impaired, with normal proximal strength but significant weakness in hip extension (L4 and L5), dorsiflexion (L4), extensor hallucis longus (L5), and plantarflexion (S1), suggesting sciatic nerve injury. She was discharged home and was pain-free off narcotics.\nAt 5 years after surgery, the patient remains pain-free. She was able to ambulate independently with a right ankle-foot orthosis. There was no evidence of locally progressive or metastatic disease on follow-up imaging. Postoperative imaging showed settling and a stable fibrous pseudoarthrosis .\nThe patient’s first pregnancy was unbeknownst to us during a period of follow-up loss after sacrectomy. However, she gave birth to a healthy 5-lb, 2-oz baby girl through a cesarean delivery at 37 weeks’ gestation by a community obstetrician. There were no birth complications. The baby, now 3½ years old, is meeting developmental milestones.\nThe Baylor Maternal-Fetal Medicine Service at Texas Children’s Pavilion for Women followed her second pregnancy closely. Frequent visits every 2 to 3 weeks were scheduled to monitor maternal status (e.g., weight gain and blood pressure). The pregnancy was carefully documented with monthly fetal ultrasound and MRI . At each outpatient visit, catheterization was performed to send urine culture, and the patient was on Keflex suppression throughout the pregnancy. Routine prenatal labs were obtained, and routine vaccines were administered. A repeat elective cesarean was performed at 37 weeks of gestation. Great care was taken to identify the right inferior epigastric vessels, the pedicle of the rectus abdominis musculocutaneous flap used for closure of the sacral defect . Plastic surgery was available at the time of delivery, but the right rectus abdominis muscle flap was not seen and was assumed to be posterior to the uterus. A healthy baby girl was delivered . The birth weight was recorded as 6 lb and 9 oz. Apgar scores of 8 and 9 were assigned at 1 and 5 min, respectively.\nTable summarizes the patient history in timeline format.\nPrior to the patient’s second pregnancy, we collected standardized and validated indices data to quantitate Health-Related Quality of Life (HRQoL) outcomes through the Oswestry Disability Index (ODI) and MOS Short Form 36 (SF-36).\nOur patient’s ODI score was 30 %, representing mild disability.\nSF-36 Physical Component Summary for our patient was calculated as 28.6 (national average, 53.5), and SF-36 Mental Component Summary was 52.9 (national average, 46.19). Our patient’s scores compared favorably in the domains of social functioning and mental health but were below the population norms across the remaining scales of physical functioning.", + "fulltext_subclaims": [ + "The patient was a 20-year-old woman.", + "She had a history of a sacral mass.", + "The sacral mass was diagnosed as benign fibrohistiocytoma by CT-guided needle biopsy 7 years before.", + "A repeat biopsy of her lesion through an open approach revealed myofibroblastic sarcoma.", + "Consideration was given for reduction of tumor burden.", + "Lumbopelvic reconstruction was considered to improve quality of life.", + "The extension of tumor into both sacroiliac joints prohibited sparing S1.", + "A two-staged total sacrectomy was planned.", + "The first stage included a midline laparotomy.", + "The first stage included mobilization of the visceral and neural structures.", + "The first stage included ligation of the internal iliac vessels.", + "A colostomy was performed.", + "A right vertical rectus abdominus myocutaneous flap based on the inferior epigastric vessels was mobilized.", + "The flap was wrapped in a bowel bag.", + "The flap was placed in the pelvis.", + "The second stage was performed the next day.", + "The second stage included L5 and S1 laminectomies.", + "The second stage included bilateral osteotomies and disarticulation of the sacrum from the ilium at the sacroiliac joints.", + "The second stage included ligation of the thecal sac inferior to the takeoff of the L5 nerve roots.", + "The second stage included complete L5–S1 discectomy.", + "The second stage included transection of the S1–S5 nerve roots.", + "The entire sacrum, along with the tumor, was removed piecemeal.", + "Lumbopelvic reconstruction was performed with spinal instrumentation and bone graft.", + "The patient had a long inpatient postoperative course.", + "She responded well to intensive physical rehabilitation.", + "Her postoperative course was complicated by a small superficial soft tissue Staphylococcus epidermidis abscess in the operative bed.", + "The abscess was treated with percutaneous drainage.", + "The abscess was treated with a full course of intravenous and oral antibiotics.", + "She developed a small ischial decubitus ulcer, remote from the surgical incision.", + "The decubitus ulcer was treated with local wound care.", + "At 3 months after surgery, the patient was able to ambulate with the assistance of a walker.", + "She had normal strength in her left leg, except for plantarflexion (S1).", + "Her right leg was more impaired, with normal proximal strength but significant weakness in hip extension (L4 and L5), dorsiflexion (L4), extensor hallucis longus (L5), and plantarflexion (S1).", + "This suggested sciatic nerve injury.", + "She was discharged home and was pain-free off narcotics.", + "At 5 years after surgery, the patient remains pain-free.", + "She was able to ambulate independently with a right ankle-foot orthosis.", + "There was no evidence of locally progressive or metastatic disease on follow-up imaging.", + "Postoperative imaging showed settling and a stable fibrous pseudoarthrosis.", + "The patient’s first pregnancy was unbeknownst to us during a period of follow-up loss after sacrectomy.", + "She gave birth to a healthy 5-lb, 2-oz baby girl through a cesarean delivery at 37 weeks’ gestation.", + "The baby, now 3½ years old, is meeting developmental milestones.", + "The Baylor Maternal-Fetal Medicine Service at Texas Children’s Pavilion for Women followed her second pregnancy closely.", + "Frequent visits every 2 to 3 weeks were scheduled to monitor maternal status.", + "The pregnancy was documented with monthly fetal ultrasound and MRI.", + "At each outpatient visit, catheterization was performed to send urine culture.", + "The patient was on Keflex suppression throughout the pregnancy.", + "Routine prenatal labs were obtained.", + "Routine vaccines were administered.", + "A repeat elective cesarean was performed at 37 weeks of gestation.", + "Great care was taken to identify the right inferior epigastric vessels.", + "Plastic surgery was available at the time of delivery.", + "The right rectus abdominis muscle flap was not seen and was assumed to be posterior to the uterus.", + "A healthy baby girl was delivered.", + "The birth weight was recorded as 6 lb and 9 oz.", + "Apgar scores of 8 and 9 were assigned at 1 and 5 min, respectively.", + "Prior to the patient’s second pregnancy, standardized and validated indices data were collected to quantitate Health-Related Quality of Life (HRQoL) outcomes.", + "The Oswestry Disability Index (ODI) score was 30 %, representing mild disability.", + "The SF-36 Physical Component Summary was calculated as 28.6.", + "The SF-36 Mental Component Summary was 52.9.", + "The patient’s scores compared favorably in the domains of social functioning and mental health.", + "The patient’s scores were below the population norms across the remaining scales of physical functioning." + ], + "summary": "We previously reported on the utilization of complete sacrectomy and lumbopelvic reconstruction for the management of primary myofibroblastic sarcoma of the sacrum and ilium in a 15-year-old female patient. In this report, we update her postoperative course with an additional 5 years of follow-up and Health-Related Quality of Life (HRQoL) outcomes. During this time period, she gave birth to two healthy full-term babies.", + "summary_subclaims": [ + "We previously reported on the utilization of complete sacrectomy and lumbopelvic reconstruction for the management of primary myofibroblastic sarcoma of the sacrum and ilium in a 15-year-old female patient.", + "In this report, we update her postoperative course with an additional 5 years of follow-up and Health-Related Quality of Life (HRQoL) outcomes.", + "During this time period, she gave birth to two healthy full-term babies." + ] + }, + { + "id": "multiclinsum_test_2875_en.txt", + "fulltext": "At the time of her DBS implantation, the patient was a 57-year-old Caucasian female who had presented with a several year history of debilitating, treatment resistant blepharospasm. Prior treatments with Botox® injections had not provided relief. After a discussion with the patient about the risks and benefits of surgical intervention, she was amenable to undergoing bilateral GPi DBS electrode placement. Planning and implantation was performed through our center’s standardized protocols, and the target was selected under direct visualization (17 mm lateral to the third ventricle wall, 5 mm below the AC PC on the left, and 3.5 mm below the AC PC).\nThe patient was followed for 7 years at the time of writing this report. During this period, she had returned for stimulation parameter manipulation 26 times . Her initial settings were a monopolar configuration with 3.1 V, 130 Hz, and 120 µs on the left electrode and 3.0 V, 130 Hz, and 130 µs on the right. Her maximal settings throughout her follow-up period were 8.1 V, 130 Hz, and 260 µs on the left and 8.0 V, 130 Hz, and 260 µs on the right. Her present settings are 7.0 V, 155 Hz, and 130 µs on the left and 6.7 V, 150 Hz, and 120 µs on the right.\nThe first phase of her programming was targeted toward symptom control. Pulse width and voltage were gradually increased to help control her symptoms while minimizing side effects. This was achieved after about 1 year when she reported that it was “the best (I’ve) felt in a long time.” On sequential visits, there were attempts to decrease the charge density delivered to the patient by decreasing either the voltage, pulse width, or both without allowing for the re-emergence of her blepharospasm.\nThroughout her follow-up, the patient also continued to receive Botox® injections and speech therapy. These synergistic interventions allowed for further decreases in delivered charge density.", + "fulltext_subclaims": [ + "The patient was a 57-year-old Caucasian female at the time of DBS implantation.", + "The patient had a several year history of debilitating, treatment resistant blepharospasm.", + "Prior treatments with Botox® injections had not provided relief.", + "The patient was amenable to undergoing bilateral GPi DBS electrode placement.", + "Planning and implantation was performed through the center’s standardized protocols.", + "The target was selected under direct visualization.", + "The target was 17 mm lateral to the third ventricle wall.", + "The target was 5 mm below the AC PC on the left.", + "The target was 3.5 mm below the AC PC on the right.", + "The patient was followed for 7 years at the time of writing this report.", + "During this period, she had returned for stimulation parameter manipulation 26 times.", + "Her initial settings were a monopolar configuration with 3.1 V, 130 Hz, and 120 µs on the left electrode.", + "Her initial settings were 3.0 V, 130 Hz, and 130 µs on the right.", + "Her maximal settings throughout her follow-up period were 8.1 V, 130 Hz, and 260 µs on the left.", + "Her maximal settings throughout her follow-up period were 8.0 V, 130 Hz, and 260 µs on the right.", + "Her present settings are 7.0 V, 155 Hz, and 130 µs on the left.", + "Her present settings are 6.7 V, 150 Hz, and 120 µs on the right.", + "The first phase of her programming was targeted toward symptom control.", + "Pulse width and voltage were gradually increased to help control her symptoms while minimizing side effects.", + "This was achieved after about 1 year when she reported that it was “the best (I’ve) felt in a long time.”", + "On sequential visits, there were attempts to decrease the charge density delivered to the patient by decreasing either the voltage, pulse width, or both.", + "The patient also continued to receive Botox® injections and speech therapy.", + "These synergistic interventions allowed for further decreases in delivered charge density." + ], + "summary": "We present a patient suffering from debilitating blepharospasm treated with bilateral DBS of the GPi alongside 7 years of stimulation parameter manipulations and a literature review of comparable patients.", + "summary_subclaims": [ + "The patient was treated with bilateral DBS of the GPi.", + "The patient had 7 years of stimulation parameter manipulations.", + "A literature review of comparable patients was included." + ] + }, + { + "id": "multiclinsum_test_2992_en.txt", + "fulltext": "This case concerns an 86-year-old man who used to be a soldier. He found a mass on the right thigh with a 2.5×2.0×1.2 cm red nodule at the beginning of May 2017. Surgical resection was performed at the local People’s Hospital. The results of pathological examination after surgery in local hospital showed a right thigh subcutaneous small cell malignant tumor of about 2.5×2.0×1.2 cm . The pathology immunohistochemistry in our hospital indicated CK-L+, Syn++, CgA+, CD56++, Ki67+, CK-H−, CK7−, CK20+, TTF-1−, CD20−, CD3−, and S100−, implying MCC. According to the pathology and immunohistochemistry, he was diagnosed with MCC T2N1M0.\nIn mid-July 2017, multiple red masses appeared in the surgical incision area, of which the largest was hard and about 1.5 cm in diameter . A metastatic lymph node was found in the right inguinal region on computed tomography (CT), ~2.2 cm in diameter without distant metastasis . Next-generation sequencing from his peripheral blood showed KDM5AG931D mutation, which may have been associated with oncogenesis.\nDue to his old age, the patient and his family members refused radiotherapy and chemotherapy. As MCC is closely related to neovascularization, antivascular therapy can be an effective treatment. As such, endostar 30 mg was administered intravenously on day 1–4 as the first cycle from August 2, 2017. After two cycles, the diameter of the major mass in the right thigh had reduced to 1 cm, and the remaining masses gradually subsided . According to the RECIST standard, efficacy reached partial response. Before the third treatment, the masses became protruding, with a recurrent trend . On CT, there was no change from before . Therefore, apatinib was added at 250 mg every other day from the third cycle beginning October 22, 2017. After the next three cycles of treatment, the masses were disappearing , while the diameter of the lymph node in the right inguinal region had reduced to 1.3 cm . In summary, after nearly 5 months (five cycles) of endostar and apatinib treatment, clinical efficacy had reached a partial response. During treatment, common adverse reactions of endostar and apatinib, such as proteinuria, hypertension, hand– foot syndrome, and hematological toxicity, did not appear.\nHowever, from the beginning of the sixth cycle on February 14, 2018, there was a new lesion of 1.2 cm diameter at the right thigh , which indicated progressive disease. He then continued to receive endostar and apatinib. At the same time, everolimus 5 mg daily and tegafur 50 mg twice daily were administered. However, he stopped taking everolimus due to serious adverse effects of weakness and vomiting after 2 months. Three treatment cycles later, the diameter of the mass had gradually increased to 3 cm . The latest CT on March 5, 2018 showed no significant changes compared with previously . The patient was followed up for about 12 months. Finally, he died of infection at the beginning of June 2018. Progression-free survival was 6.5 months and overall survival 13.0 months.\nThe patient’s family provided written informed consent for publication of this report and accompanying images. We confirmed with the institutional review board of the First Affiliated Hospital of Nanjing Medical University that institutional approval was not required to publish this case report.", + "fulltext_subclaims": [ + "The patient was an 86-year-old man.", + "He found a mass on the right thigh with a 2.5×2.0×1.2 cm red nodule at the beginning of May 2017.", + "Surgical resection was performed at the local People’s Hospital.", + "The results of pathological examination after surgery in the local hospital showed a right thigh subcutaneous small cell malignant tumor of about 2.5×2.0×1.2 cm.", + "The pathology immunohistochemistry in our hospital indicated CK-L+, Syn++, CgA+, CD56++, Ki67+, CK-H−, CK7−, CK20+, TTF-1−, CD20−, CD3−, and S100−.", + "He was diagnosed with MCC T2N1M0.", + "In mid-July 2017, multiple red masses appeared in the surgical incision area.", + "The largest mass was hard and about 1.5 cm in diameter.", + "A metastatic lymph node was found in the right inguinal region on computed tomography (CT), ~2.2 cm in diameter.", + "Next-generation sequencing from his peripheral blood showed KDM5AG931D mutation.", + "The patient and his family members refused radiotherapy and chemotherapy.", + "Endostar 30 mg was administered intravenously on day 1–4 as the first cycle from August 2, 2017.", + "After two cycles, the diameter of the major mass in the right thigh had reduced to 1 cm.", + "The remaining masses gradually subsided.", + "According to the RECIST standard, efficacy reached partial response.", + "Before the third treatment, the masses became protruding, with a recurrent trend.", + "On CT, there was no change from before.", + "Apatinib was added at 250 mg every other day from the third cycle beginning October 22, 2017.", + "After the next three cycles of treatment, the masses were disappearing.", + "The diameter of the lymph node in the right inguinal region had reduced to 1.3 cm.", + "After nearly 5 months (five cycles) of endostar and apatinib treatment, clinical efficacy had reached a partial response.", + "Common adverse reactions of endostar and apatinib, such as proteinuria, hypertension, hand–foot syndrome, and hematological toxicity, did not appear.", + "From the beginning of the sixth cycle on February 14, 2018, there was a new lesion of 1.2 cm diameter at the right thigh.", + "The patient then continued to receive endostar and apatinib.", + "Everolimus 5 mg daily and tegafur 50 mg twice daily were administered.", + "He stopped taking everolimus due to serious adverse effects of weakness and vomiting after 2 months.", + "Three treatment cycles later, the diameter of the mass had gradually increased to 3 cm.", + "The latest CT on March 5, 2018 showed no significant changes compared with previously.", + "The patient was followed up for about 12 months.", + "He died of infection at the beginning of June 2018.", + "Progression-free survival was 6.5 months.", + "Overall survival was 13.0 months.", + "The patient’s family provided written informed consent for publication of this report and accompanying images.", + "Institutional approval was not required to publish this case report." + ], + "summary": "The current study describes the case of an 86-year-old retired man, who presented with a 2.5×2.0×1.2 cm red nodule on the right thigh, which was initially diagnosed as subcutaneous small cell cancer. Upon histological and immunohistochemical analysis, the tumor was consistent with a diagnosis of MCC.", + "summary_subclaims": [ + "The patient is an 86-year-old retired man.", + "The lesion was a 2.5×2.0×1.2 cm red nodule on the right thigh.", + "The lesion was initially diagnosed as subcutaneous small cell cancer.", + "Histological and immunohistochemical analysis was performed.", + "The tumor was consistent with a diagnosis of MCC." + ] + }, + { + "id": "multiclinsum_test_1065_en.txt", + "fulltext": "We describe the case of a 25-year-old black Cameroonian woman of Bakossi origin with basic primary education, gravida 3 para 1 (G3P1010), who lost a child in 2012 following complications of neonatal infection and later had an abortion in early 2015. She presented to a district hospital in the South-West Region of Cameroon for her first antenatal visit with a 21-week pregnancy. Her blood pressure was 107/66 mmHg and she had a uterine fundal height of 26 cm.\nShe was requested to do some paraclinical examinations including blood group, hemoglobin level, glycemia, human immunodeficiency virus (HIV), syphilis, toxoplasma, rubella serology, stool analysis, urine analysis, and a fetal ultrasound. Most of these tests were done and were found to be normal. However, toxoplasma and rubella immunoglobulin G (IgG) serologic tests were both reactive; analysis was done with the aid of ImmunoComb® IgG and ImmunoComb® II IgG serologic tests, respectively. She also had a proteinuria of 100 mg/dl; her blood group is AB rhesus positive. She did not benefit from a morphologic fetal ultrasound partly because there was none in the hospital and because of the financial constraints she presented, which limited her movement to the nearest regional referral hospital located approximately 100 km from the site of her antenatal clinic via a poorly accessible road. She was, however, put on daily 65 mg of elemental iron and 5 mg of folic acid supplement, and she received anti-tetanus vaccine, intermittent preventive treatment against malaria, and a long-acting insecticide-treated bed net. She was encouraged to consult a gynecologist-obstetrician at the nearest referral hospital.\nBy her next antenatal visit 4 weeks later, she had not consulted the specialist physician and was still unable to attend the paraclinical examination requested earlier. Emphasis was placed on the risk of her baby sustaining life-threatening malformations and she was advised to continue with the supplements and follow-up visits. She was again encouraged to undergo a fetal ultrasound and to consult a gynecologist-obstetrician. Adding to the challenges faced by this expectant mother, the district hospital did not have an ambulance that could have helped the health care provider to overcome the road accessibility and financial challenges she faced.\nDuring her 34th week of pregnancy she returned to the hospital in labor pains with a blood pressure of 110/68 mmHg, uterine fundal height of 40 cm, and was at 8 cm cervical dilation with bulging membranes. After placing her on a 5% glucose infusion, the membranes were ruptured, and a turbid amniotic fluid of approximately 2000 ml oozed out. This was followed by the delivery of an anencephalic recently dead baby boy weighing 1600 g. Active management of third stage of labor was done (Additional file ).\nThe devastated mother and her partner received psychosocial care for 3 days; she was discharged from hospital and scheduled for routine psychosocial follow-up. She was further counseled on the need to consult a gynecologist-obstetrician before her next pregnancy.", + "fulltext_subclaims": [ + "The patient is a 25-year-old black Cameroonian woman of Bakossi origin.", + "She has basic primary education.", + "She is gravida 3 para 1.", + "She lost a child in 2012 following complications of neonatal infection.", + "She had an abortion in early 2015.", + "She presented to a district hospital in the South-West Region of Cameroon for her first antenatal visit.", + "She had a 21-week pregnancy at the time of presentation.", + "Her blood pressure was 107/66 mmHg.", + "Her uterine fundal height was 26 cm.", + "She was requested to do paraclinical examinations including blood group, hemoglobin level, glycemia, HIV, syphilis, toxoplasma, rubella serology, stool analysis, urine analysis, and a fetal ultrasound.", + "Most of these tests were done and were found to be normal.", + "Toxoplasma and rubella immunoglobulin G (IgG) serologic tests were both reactive.", + "Analysis was done with the aid of ImmunoComb® IgG and ImmunoComb® II IgG serologic tests.", + "She had a proteinuria of 100 mg/dl.", + "Her blood group is AB rhesus positive.", + "She did not benefit from a morphologic fetal ultrasound.", + "There was no morphologic fetal ultrasound in the hospital.", + "She had financial constraints.", + "The nearest regional referral hospital was approximately 100 km from the site of her antenatal clinic.", + "The road to the regional referral hospital was poorly accessible.", + "She was put on daily 65 mg of elemental iron.", + "She received 5 mg of folic acid supplement.", + "She received anti-tetanus vaccine.", + "She received intermittent preventive treatment against malaria.", + "She received a long-acting insecticide-treated bed net.", + "She was encouraged to consult a gynecologist-obstetrician at the nearest referral hospital.", + "By her next antenatal visit 4 weeks later, she had not consulted the specialist physician.", + "She was still unable to attend the paraclinical examination requested earlier.", + "She was advised to continue with the supplements and follow-up visits.", + "She was again encouraged to undergo a fetal ultrasound.", + "She was again encouraged to consult a gynecologist-obstetrician.", + "The district hospital did not have an ambulance.", + "During her 34th week of pregnancy she returned to the hospital in labor pains.", + "Her blood pressure was 110/68 mmHg.", + "Her uterine fundal height was 40 cm.", + "She was at 8 cm cervical dilation with bulging membranes.", + "After placing her on a 5% glucose infusion, the membranes were ruptured.", + "A turbid amniotic fluid of approximately 2000 ml oozed out.", + "This was followed by the delivery of an anencephalic recently dead baby boy weighing 1600 g.", + "Active management of third stage of labor was done.", + "The mother and her partner received psychosocial care for 3 days.", + "She was discharged from hospital.", + "She was scheduled for routine psychosocial follow-up.", + "She was counseled on the need to consult a gynecologist-obstetrician before her next pregnancy." + ], + "summary": "A 25-year-old black Cameroonian woman of Bakossi origin, gravida3 para1010, presented with a positive rubella and toxoplasma immunoglobulin G serologic test at 21 weeks of pregnancy; she could not benefit from a fetal morphologic ultrasound partly because there was none at the site of her antenatal clinic and because there were accessibility constraints getting to the nearest referral hospital approximately 100 km away. She returned to the hospital in labor pains 14 weeks later and, upon examination, she was observed to be at almost full cervical dilatation and had a stillbirth a few minutes later; a baby boy weighing 1600 g with anencephaly. The devastated parents of the baby were counseled and given psychological support. She was discharged from hospital 3 days later and now benefits from continual follow up as out-patient. She was advised to consult a gynecologist-obstetrician before her next pregnancy.", + "summary_subclaims": [ + "The patient is a 25-year-old black Cameroonian woman of Bakossi origin.", + "She is gravida3 para1010.", + "She had a positive rubella immunoglobulin G serologic test at 21 weeks of pregnancy.", + "She had a positive toxoplasma immunoglobulin G serologic test at 21 weeks of pregnancy.", + "She could not benefit from a fetal morphologic ultrasound partly because there was none at the site of her antenatal clinic.", + "She could not benefit from a fetal morphologic ultrasound partly because there were accessibility constraints getting to the nearest referral hospital approximately 100 km away.", + "She returned to the hospital in labor pains 14 weeks later.", + "Upon examination, she was observed to be at almost full cervical dilatation.", + "She had a stillbirth a few minutes later.", + "The stillborn baby was a boy weighing 1600 g.", + "The baby had anencephaly.", + "The parents of the baby were counseled.", + "The parents of the baby were given psychological support.", + "She was discharged from hospital 3 days later.", + "She now benefits from continual follow up as out-patient.", + "She was advised to consult a gynecologist-obstetrician before her next pregnancy." + ] + }, + { + "id": "multiclinsum_test_1743_en.txt", + "fulltext": "A 77-year-old lady presented with the complaints of a left-sided breast lump of 1-month duration. She had been a heart patient and had been on treatment for the last 4 years. On clinical examination a 3 × 2 cm firm, mobile, non-tender lump was identified in the outer quadrant of her left breast. The overlying skin of the breast along with nipple and areola were unremarkable. There was no significant axillary or cervical lymphadenopathy. The other breast was normal. She underwent a mammographic examination, followed by fine needle aspiration cytology (FNAC) that was essentially inconclusive. Subsequently, she underwent a frozen section for a primary diagnosis.\nOn mammography, a 2 × 2 cm ill-defined mass with irregular margins was identified in the left upper outer quadrant. No micro-calcifications were seen. The right-sided breast was normal. .\nThe lumpectomy specimen on cut surface revealed a firm, grey-white, fibrous, un-encapsulated nodular tumor measuring 2 × 1.2 × 0.8 cm with infiltrative borders. No area of calcification was identified. The closest margin was the base and was found to be 0.5 cm away from the tumor.\nFrozen sections revealed a tumor with predominant spindle cells showing mild atypia, amidst a sclerotic stroma and conspicuously infiltrated the adjacent fat. A diagnosis of a low-grade sarcoma was favored over a metaplastic carcinoma. Therefore, a sentinel lymph node biopsy and/or an axillary node dissection (ALND) were not conducted at the time of surgery.\nHistological sections revealed a spindle cell tumor showing an infiltrative growth pattern with prominent areas of sclerosis reminiscent of keloid formation. The cells were mainly arranged in fascicles and displayed tapering nuclei with mild anisonucleosis. Mitoses were inconspicuous. Occasionally, the cells were plump with epithelioid shapes and revealed mild atypia with an occasional small cluster formation. Interspersed were foci of benign ductal hyperplasia and papillary hyperplasia, including a micropapilloma along with focal aggregates of chronic inflammatory cells. The micropapilloma did not show any significant atypia. . No discrete squamous differentiation was identified. No focus of Ductal-carcinoma-in-situ (DCIS) was seen in any of the sections. The two closest differential diagnoses considered were fibromatosis and a \"fibromatosis like\" metaplastic carcinoma. A wide panel of IHC antibody markers was performed . The tumor cells were simultaneously diffusely positive for epithelial markers i.e. the various cytokeratins CK, CK7, High molecular weight (HMWCK) and epithelial membrane antigen (EMA), along with a mesenchymal marker i.e. vimentin. . All the cytokeratins were positive in the interspersed benign ducts that acted as internal controls. The tumor cells were negative for Gross cystic disease fluid protein (GCDFP), estrogen (ER) and progesterone receptor (PR). The myoepithelial markers i.e. smooth muscle actin (SMA) and p63 showed focal, positive expression. . S100 and Desmin were negative. Ki-67 (proliferation marker) showed focal positivity in less than 5% tumor cells . The tumor cells were negative for CD34 and CerbB-2/HER-2/neu. . A diagnosis of a low-grade \"fibromatosis-like\" metaplastic carcinoma, associated with a micropapilloma, was finally made. All the cut margins were free of tumor.\nA portion of fresh tumor tissue fixed in 3% glutaraldehyde was processed for electron microscopy. Ultra thin sections stained with uranyl acetate and lead citrate were observed under an electron microscope model: Zeiss 109, Germany.\nUltrastructurally, the tumor cells embedded in a collagenous stroma showed fibroblastic and myoepithelial features along with presence of peripheral villous processes with a focal basal lamina and intercellular junctions .\nAfter surgery, the patient completed adjuvant radiotherapy (RT). Thereafter, she has been on a regular 2 monthly follow-up; including her metastatic work-up with Positron emission tomography (PET-CT) of the body and bone scan. Due to a high cardiac risk, a second surgery for an ALND was not performed. Nevertheless, till 1 year and 4 months of her follow-up she has not been identified with any lymphadenopathy, recurrent lesion or metastatic lesions in her body.", + "fulltext_subclaims": [ + "The patient is a 77-year-old lady.", + "She presented with a left-sided breast lump of 1-month duration.", + "She had been a heart patient for the last 4 years.", + "A 3 × 2 cm firm, mobile, non-tender lump was identified in the outer quadrant of her left breast.", + "The overlying skin of the breast along with nipple and areola were unremarkable.", + "There was no significant axillary or cervical lymphadenopathy.", + "The other breast was normal.", + "She underwent a mammographic examination.", + "She underwent fine needle aspiration cytology (FNAC).", + "FNAC was essentially inconclusive.", + "She underwent a frozen section for a primary diagnosis.", + "On mammography, a 2 × 2 cm ill-defined mass with irregular margins was identified in the left upper outer quadrant.", + "No micro-calcifications were seen.", + "The right-sided breast was normal.", + "The lumpectomy specimen on cut surface revealed a firm, grey-white, fibrous, un-encapsulated nodular tumor measuring 2 × 1.2 × 0.8 cm with infiltrative borders.", + "No area of calcification was identified.", + "The closest margin was the base and was found to be 0.5 cm away from the tumor.", + "Frozen sections revealed a tumor with predominant spindle cells showing mild atypia, amidst a sclerotic stroma and conspicuously infiltrated the adjacent fat.", + "A diagnosis of a low-grade sarcoma was favored over a metaplastic carcinoma.", + "A sentinel lymph node biopsy and/or an axillary node dissection (ALND) were not conducted at the time of surgery.", + "Histological sections revealed a spindle cell tumor showing an infiltrative growth pattern with prominent areas of sclerosis reminiscent of keloid formation.", + "The cells were mainly arranged in fascicles and displayed tapering nuclei with mild anisonucleosis.", + "Mitoses were inconspicuous.", + "Occasionally, the cells were plump with epithelioid shapes and revealed mild atypia with an occasional small cluster formation.", + "Interspersed were foci of benign ductal hyperplasia and papillary hyperplasia, including a micropapilloma.", + "The micropapilloma did not show any significant atypia.", + "No discrete squamous differentiation was identified.", + "No focus of Ductal-carcinoma-in-situ (DCIS) was seen in any of the sections.", + "The two closest differential diagnoses considered were fibromatosis and a 'fibromatosis like' metaplastic carcinoma.", + "A wide panel of IHC antibody markers was performed.", + "The tumor cells were simultaneously diffusely positive for epithelial markers i.e. the various cytokeratins CK, CK7, High molecular weight (HMWCK) and epithelial membrane antigen (EMA), along with a mesenchymal marker i.e. vimentin.", + "All the cytokeratins were positive in the interspersed benign ducts that acted as internal controls.", + "The tumor cells were negative for Gross cystic disease fluid protein (GCDFP), estrogen (ER) and progesterone receptor (PR).", + "The myoepithelial markers i.e. smooth muscle actin (SMA) and p63 showed focal, positive expression.", + "S100 and Desmin were negative.", + "Ki-67 showed focal positivity in less than 5% tumor cells.", + "The tumor cells were negative for CD34 and CerbB-2/HER-2/neu.", + "A diagnosis of a low-grade 'fibromatosis-like' metaplastic carcinoma, associated with a micropapilloma, was finally made.", + "All the cut margins were free of tumor.", + "A portion of fresh tumor tissue fixed in 3% glutaraldehyde was processed for electron microscopy.", + "Ultra thin sections stained with uranyl acetate and lead citrate were observed under an electron microscope model: Zeiss 109, Germany.", + "Ultrastructurally, the tumor cells embedded in a collagenous stroma showed fibroblastic and myoepithelial features along with presence of peripheral villous processes with a focal basal lamina and intercellular junctions.", + "After surgery, the patient completed adjuvant radiotherapy (RT).", + "She has been on a regular 2 monthly follow-up.", + "Her metastatic work-up included Positron emission tomography (PET-CT) of the body and bone scan.", + "Due to a high cardiac risk, a second surgery for an ALND was not performed.", + "Till 1 year and 4 months of her follow-up she has not been identified with any lymphadenopathy, recurrent lesion or metastatic lesions in her body." + ], + "summary": "A 77-year-old lady presented with a 2 x 2 cm mass with irregular margins in the upper and outer quadrant of left breast. Fine needle aspiration cytology (FNAC) from the lump was inconclusive. A lumpectomy was performed and sent for frozen section, which revealed presence of spindle cells showing mild atypia in a sclerotic stroma. The tumor cells revealed prominent infiltration into the adjacent fat. A differential diagnosis of a low-grade sarcoma vs. a metaplastic carcinoma, favoring the former, was offered. Final histology sections revealed an infiltrating tumor with predominant spindle cells in a collagenous background, simulating a fibromatosis. Adjacent to the tumor were foci of benign ductal hyperplasia and a micropapilloma. Immunohistochemistry (IHC) showed diffuse co-expression of epithelial markers i.e. cytokeratins (CK, HMWCK, CK7) and EMA along with a mesenchymal marker i.e. vimentin in the tumor cells. Myoepithelial markers (SMA and p63) showed focal positivity. A diagnosis of a low-grade fibromatosis-like carcinoma breast associated with a micropapilloma was formed.", + "summary_subclaims": [ + "The patient is a 77-year-old lady.", + "She had a 2 x 2 cm mass with irregular margins in the upper and outer quadrant of the left breast.", + "Fine needle aspiration cytology from the lump was inconclusive.", + "A lumpectomy was performed.", + "Frozen section revealed presence of spindle cells showing mild atypia in a sclerotic stroma.", + "The tumor cells revealed prominent infiltration into the adjacent fat.", + "A differential diagnosis of a low-grade sarcoma vs. a metaplastic carcinoma, favoring the former, was offered.", + "Final histology sections revealed an infiltrating tumor with predominant spindle cells in a collagenous background, simulating a fibromatosis.", + "Adjacent to the tumor were foci of benign ductal hyperplasia and a micropapilloma.", + "Immunohistochemistry showed diffuse co-expression of epithelial markers i.e. cytokeratins (CK, HMWCK, CK7) and EMA along with a mesenchymal marker i.e. vimentin in the tumor cells.", + "Myoepithelial markers (SMA and p63) showed focal positivity.", + "A diagnosis of a low-grade fibromatosis-like carcinoma breast associated with a micropapilloma was formed." + ] + }, + { + "id": "multiclinsum_test_748_en.txt", + "fulltext": "A twenty-year-old female presented to the oral medicine clinic at the Faculty of Dentistry, Alexandria University. The patient complained of a reddish painful area on the tongue, that started one year ago and has been increasing in size over time . The patient reported completing an orthodontic treatment two years ago after which she has been using a Hawley retainer for orthodontic retention .\nNo specific findings were found on medical history taking and extraoral examination. Intraoral examination revealed a reddish patch on the left dorsolateral surface of the tongue surrounded by whitish lines. The lesion measured 2 × 3 cm, had normal consistency, smooth surface texture, and normal surrounding tissues . Another lesion in the form of a white keratotic plaque on the right dorsolateral surface of the tongue was found upon clinical examination. It was of 1 cm in size with normal consistency and normal surrounding tissues .\nThe initial differential diagnoses included erythroplakia (because of the fiery red color), lichenoid contact reaction (because of the Hawley retainer), and geographic tongue (because of the location and age). An incisional biopsy was taken and subjected to histopathological examination to aid in reaching a conclusive diagnosis.\nThe soft tissue section showed keratinized stratified squamous epithelium of variable thickness. Atrophic areas were predominantly present, other areas showed hyperplasia or epithelial proliferation in the underlying lamina propria. Degeneration of the basal epithelial cells and the basement membrane was evident. There was a dense, band-like lymphocytic infiltrate in the lamina propria that obscured the epithelial-connective tissue junction. Additionally, numerous dysplastic criteria such as hyperchromatism, pleomorphism, prominent nucleoli and mitotic figures were evident .\nHistopathological results suggested the diagnosis of OLR. In an attempt to confirm this diagnosis, we performed a patch test by applying grinded acrylic resin, similar to that used in the construction of the Hawley retainer, on the forearm for 72 h and instructed the patient to report any kind of discomfort. After 72 h, there was desquamation, erythema and pigmentation of the skin suggesting a positive patch test, which confirmed our diagnosis .\nWe instructed the patient to discontinue using the Hawley retainer, replaced it by a vacuum retainer, and prescribed topical corticosteroids to decrease patient’s discomfort. Three weeks later, partial resolution of the lesion was evident. We followed the patient for six months with no signs of lesions recurrence .", + "fulltext_subclaims": [ + "A twenty-year-old female presented to the oral medicine clinic at the Faculty of Dentistry, Alexandria University.", + "The patient complained of a reddish painful area on the tongue that started one year ago.", + "The patient reported completing an orthodontic treatment two years ago.", + "The patient has been using a Hawley retainer for orthodontic retention.", + "Intraoral examination revealed a reddish patch on the left dorsolateral surface of the tongue surrounded by whitish lines.", + "The lesion measured 2 × 3 cm with normal consistency and smooth surface texture.", + "Another lesion in the form of a white keratotic plaque on the right dorsolateral surface of the tongue was found.", + "The white keratotic plaque was 1 cm in size with normal consistency.", + "The initial differential diagnoses included erythroplakia, lichenoid contact reaction, and geographic tongue.", + "An incisional biopsy was taken and subjected to histopathological examination.", + "The soft tissue section showed keratinized stratified squamous epithelium of variable thickness.", + "Degeneration of the basal epithelial cells and the basement membrane was evident.", + "There was a dense, band-like lymphocytic infiltrate in the lamina propria.", + "Numerous dysplastic criteria such as hyperchromatism, pleomorphism, prominent nucleoli, and mitotic figures were evident.", + "Histopathological results suggested the diagnosis of OLR.", + "A patch test was performed by applying grinded acrylic resin similar to that used in the Hawley retainer.", + "After 72 hours, there was desquamation, erythema, and pigmentation of the skin.", + "The positive patch test confirmed the diagnosis.", + "The patient was instructed to discontinue using the Hawley retainer.", + "The patient was prescribed topical corticosteroids.", + "Three weeks later, partial resolution of the lesion was evident.", + "The patient was followed for six months with no signs of lesion recurrence." + ], + "summary": "A female patient (twenty years of age) has been complaining of a reddish painful area on the tongue, which started one year ago and has been increasing in size over time. The patient completed orthodontic treatment two years ago and has been using a Hawley retainer for orthodontic retention since then. After performing histological analysis and patch test, the lesion was diagnosed as a lichenoid reaction to the Hawley retainer. Topical corticosteroids were prescribed, and the patient was asked to stop using the retainer and followed for six months.", + "summary_subclaims": [ + "The patient is a female twenty years of age.", + "The patient has been complaining of a reddish painful area on the tongue.", + "The reddish painful area on the tongue started one year ago.", + "The lesion has been increasing in size over time.", + "The patient completed orthodontic treatment two years ago.", + "The patient has been using a Hawley retainer for orthodontic retention since completing orthodontic treatment.", + "Histological analysis and patch test were performed.", + "The lesion was diagnosed as a lichenoid reaction to the Hawley retainer.", + "Topical corticosteroids were prescribed.", + "The patient was asked to stop using the retainer.", + "The patient was followed for six months." + ] + }, + { + "id": "multiclinsum_test_1911_en.txt", + "fulltext": "A 60-year-old Japanese woman with severe anemia complained of several episodes of black stool over the preceding 2 years. Upper and lower gastrointestinal tract endoscopies were performed at another hospital and the findings were unremarkable. She was referred to our hospital for further evaluation. Blood tests confirmed the known anemia (hemoglobin 7.2g/dL; normal range 13.0–15.5g/dL) with iron deficiency (iron 12μg/dL; normal range 50–140μg/dL).\nAn abdominal CT showed a 3.0-cm low-density tumor in the ileum, indicative of an intestinal lipoma . Intermittent episodes of melena continued after admission, leading us to perform retrograde DBE to enable diagnosis and treatment.\nDBE images displayed a dumbbell-shaped tumor (30 × 35mm) on the anti-mesenteric side of the ileum, approximately 85cm from the ileocecal valve . A similar finding was shown by selective contrast-enhanced radiography . The cushion sign was detected when the biopsy forceps were pushed into the tumor. This sign usually confirms the diagnosis of intestinal lipomas. EUS revealed a hypo-echoic layer corresponding to the muscularis propria and a hyper-echoic layer corresponding to the fat tissue . These findings, which suggested that the tumor included areas outside the intestinal serosa, are not typical for a lipoma, despite the existence of a hyper-echoic layer corresponding to fatty tissue. Based on these findings inverted Meckel’s diverticulum was suspected as possible diagnosis and laparoscopic surgery was considered to be the appropriate treatment. A surgical specimen showed ectopic pancreatic tissue around the top of a tumor-like elevation, thus confirming our diagnosis.\nThe postoperative course was uneventful and the patient was discharged with an improvement in anemia.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Japanese woman.", + "She had severe anemia.", + "She had episodes of black stool over the preceding 2 years.", + "Upper and lower gastrointestinal tract endoscopies were performed at another hospital.", + "The findings of the endoscopies were unremarkable.", + "She was referred to our hospital for further evaluation.", + "Blood tests confirmed the known anemia with a hemoglobin level of 7.2g/dL.", + "The normal range for hemoglobin is 13.0–15.5g/dL.", + "Iron deficiency was confirmed with an iron level of 12μg/dL.", + "An abdominal CT showed a 3.0-cm low-density tumor in the ileum.", + "The CT findings were indicative of an intestinal lipoma.", + "Intermittent episodes of melena continued after admission.", + "Retrograde DBE was performed.", + "DBE images displayed a dumbbell-shaped tumor on the anti-mesenteric side of the ileum.", + "The tumor was approximately 85cm from the ileocecal valve.", + "A similar finding was shown by selective contrast-enhanced radiography.", + "The cushion sign was detected when the biopsy forceps were pushed into the tumor.", + "The cushion sign usually confirms the diagnosis of intestinal lipomas.", + "EUS revealed a hypo-echoic layer corresponding to the muscularis propria.", + "EUS also revealed a hyper-echoic layer corresponding to the fat tissue.", + "The findings suggested that the tumor included areas outside the intestinal serosa.", + "These findings are not typical for a lipoma.", + "Inverted Meckel’s diverticulum was suspected as a possible diagnosis.", + "Laparoscopic surgery was considered to be the appropriate treatment.", + "A surgical specimen showed ectopic pancreatic tissue around the top of a tumor-like elevation.", + "The postoperative course was uneventful.", + "The patient was discharged with an improvement in anemia." + ], + "summary": "A 60-year-old Japanese woman with severe anemia complained of several episodes of black stool over the preceding 2 years. Abdominal computed tomography showed a 3.0-cm low-density tumor in the ileum, suggesting a diagnosis of intestinal lipoma. Examination of the tumor by endoscopic ultrasound with double-balloon endoscopy revealed a hypo-echoic layer corresponding to the muscularis propria, and a hyper-echoic layer corresponding to the fat tissue. These findings, which suggested that the tumor included areas outside the intestinal serosa, are not typical for a lipoma, despite the existence of a hyper-echoic layer corresponding to fatty tissue. We then considered a diagnosis of inverted Meckel's diverticulum.", + "summary_subclaims": [ + "The patient is a 60-year-old Japanese woman.", + "The patient had severe anemia.", + "The patient had several episodes of black stool over the preceding 2 years.", + "Abdominal computed tomography showed a 3.0-cm low-density tumor in the ileum.", + "The tumor was suggested to be a diagnosis of intestinal lipoma.", + "Examination of the tumor by endoscopic ultrasound with double-balloon endoscopy revealed a hypo-echoic layer corresponding to the muscularis propria.", + "Examination of the tumor by endoscopic ultrasound with double-balloon endoscopy revealed a hyper-echoic layer corresponding to the fat tissue.", + "The findings suggested that the tumor included areas outside the intestinal serosa.", + "These findings are not typical for a lipoma.", + "The tumor had a hyper-echoic layer corresponding to fatty tissue.", + "We then considered a diagnosis of inverted Meckel's diverticulum." + ] + }, + { + "id": "multiclinsum_test_2050_en.txt", + "fulltext": "A 60-year-old male was referred to our clinic for a large AAA detected during ultrasound screening of the abdominal aorta during cardiovascular screening check-up.\nHe had a history of heavy smoking (50 pack years). The patient had developed mild shortness of breath for the past 3 wk. Coronary angiography revealed chronic total occlusion of the mid right coronary artery with good collateral blood supply from the left coronary artery. Percutaneous coronary intervention was deferred as symptoms subsided after medical therapy. The patient was then referred to our clinic after the screening abdominal ultrasound revealed a CAAA.\nThe patient had a history of hypertension and renal tuberculosis 5-years prior. His electrocorticography performance status was also dramatically decreased from 4 to 2 after his diagnosis of renal tuberculosis.\nThe patient had not any personal or family history.\nA pulsating mass was palpable in the peri-umbilical area.\nThe baseline creatinine level was 1.1 mg/dL. Other laboratory findings were all within normal limit.\nComputed tomographic aortography (CTA) was performed successfully. The diagnosis was made based on the serial axial images and its Three-dimensional reconstruction of the CTA. The patient had a Crawford type IV CAAA consisting of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level . The proximal AAA was a fusiform juxtarenal aneurysm (max diameter: 79 mm), starting directly below a sharp kink at the diaphragm level and ending at approximately 4 cm distal to the RA . The distal aneurysm (max diameter: 49 mm) was fusiform starting 5 cm distal to the RA and involving both the CIAs, where occlusion of the right internal iliac artery (IIA) was observed .", + "fulltext_subclaims": [ + "A 60-year-old male was referred to our clinic for a large AAA detected during ultrasound screening of the abdominal aorta during cardiovascular screening check-up.", + "He had a history of heavy smoking (50 pack years).", + "The patient had developed mild shortness of breath for the past 3 wk.", + "Coronary angiography revealed chronic total occlusion of the mid right coronary artery with good collateral blood supply from the left coronary artery.", + "Percutaneous coronary intervention was deferred as symptoms subsided after medical therapy.", + "The patient was then referred to our clinic after the screening abdominal ultrasound revealed a CAAA.", + "The patient had a history of hypertension and renal tuberculosis 5-years prior.", + "His electrocorticography performance status was also dramatically decreased from 4 to 2 after his diagnosis of renal tuberculosis.", + "The patient had not any personal or family history.", + "A pulsating mass was palpable in the peri-umbilical area.", + "The baseline creatinine level was 1.1 mg/dL.", + "Other laboratory findings were all within normal limit.", + "Computed tomographic aortography (CTA) was performed successfully.", + "The diagnosis was made based on the serial axial images and its Three-dimensional reconstruction of the CTA.", + "The patient had a Crawford type IV CAAA consisting of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.", + "The proximal AAA was a fusiform juxtarenal aneurysm (max diameter: 79 mm), starting directly below a sharp kink at the diaphragm level and ending at approximately 4 cm distal to the RA.", + "The distal aneurysm (max diameter: 49 mm) was fusiform starting 5 cm distal to the RA and involving both the CIAs, where occlusion of the right internal iliac artery (IIA) was observed." + ], + "summary": "A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm (CAAA) starting directly distal to the diaphragm extending to both common iliac arteries (CIAs). The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level. Due to the poor performance of the patient and the expansive disease, we planned a stepwise-combined surgery and EVAR to minimize invasiveness. A branched graft was implanted after surgical debranching of the visceral and RA. Since the patient had renal and liver injury after surgery, the second stage EVAR was performed 10 mo later. The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR. The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.", + "summary_subclaims": [ + "The patient is a 60-year-old male.", + "The patient had a Crawford type IV complex thoracoabdominal aortic aneurysm.", + "The aneurysm started directly distal to the diaphragm.", + "The aneurysm extended to both common iliac arteries.", + "The aneurysm consisted of a proximal and distal aneurysmal sac.", + "There was a 1 cm-healthy zone in the infrarenal level.", + "The patient had poor performance.", + "The patient had expansive disease.", + "A stepwise-combined surgery and EVAR was planned.", + "A branched graft was implanted after surgical debranching of the visceral and RA.", + "The patient had renal and liver injury after surgery.", + "The second stage EVAR was performed 10 mo later.", + "The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.", + "The patient has been uneventful for 5-years after discharge.", + "The patient is being followed in the outpatient clinic." + ] + }, + { + "id": "multiclinsum_test_1545_en.txt", + "fulltext": "A 51-year-old Japanese woman presented to our facility for her regular physical examination. Chest radiographs showed pleural wall thickening on the right side of the apex and upper lung field, which had been seen for several years on her annual regular examinations . She had had a mild dry cough for two weeks without symptoms of a common cold such as sore throat and fever. She was a smoker (20 cigarettes per day for 20 years). She had no history of lung disease, such as bacterial pneumonia or pulmonary tuberculosis.\nA chest high-resolution CT scan was performed for detailed examination and showed multiple nodular lesions (mostly GGOs) throughout the lung fields, approximately 1cm or less in diameter, which were not detected on chest radiographs . No cystic lesions, pleural effusions, or mediastinal lymph node swellings were observed. Bone sclerosis lesions were detected at Th3, Th6, and the first costal bone . The findings seen on the right side of the upper lung fields on chest radiographs were evaluated as old inflammatory changes based on the chest CT scan; their etiology seemed to be different from the multiple nodular GGOs (data not shown).\nOur patient was referred to our hospital for further investigation and treatment. The differential diagnoses of the lung GGOs were atypical adenomatous hyperplasia (AAH), highly differentiated adenocarcinoma in situ (AIS), lymphoproliferative disease, and MMPH. Her physical findings were normal. Breath sounds were normal, and no rales were heard on chest auscultation. No skin lesions such as facial angiofibroma and hypomelanotic macules were observed. A neurological examination showed no abnormalities. She had no intellectual disability and no history of epilepsy or other diseases. There was no family history of TSC. There were no abnormal laboratory test results at the time of her first visit to our hospital. Arterial blood gas analysis results were also normal. Pulmonary function tests were normal except for a mild decrease in diffusing capacity for carbon monoxide (DLCO).\nTo further investigate the multiple nodular lung lesions, video-assisted thoracoscopic biopsies of the left upper lobe (S5) and the left lower lobe (S9) were performed. The lesions were found to be tinged white on macroscopic examination . Microscopically, the nodules were well demarcated and consisted of papillary growths of hyperplastic type II pneumocytes accompanied with nuclear inclusion bodies and fibrous thickening of alveolar septa accompanied with increased elastic fibers, resulting in the collapse of the alveolar space . Elastica van Gieson staining revealed increased elastic tissue fibers in the lesions . No cystic lesions were detected. Human Melanoma Black (HMB)-45-positive cells, a characteristic feature of LAM, were not observed on immunohistochemical staining (data not shown). These histological findings were consistent with MMPH.\nA subsequent CT scan suggested that there were bilateral renal angiomyolipomas . Brain magnetic resonance imaging (MRI) demonstrated multiple high intensity areas of cortical and subcortical tubers . All of these findings, including bone, kidney, and brain manifestations, are typical features of TSC , and the latter two findings are major diagnostic criteria for TSC .\nFinally, from the comprehensive assessment including the histological findings of lung nodular lesions and the CT and MRI findings of TSC, such as renal angiomyolipoma, cortical and subcortical tubers, and vertebral bone sclerosis, our patient was diagnosed as having TSC with MMPH, though she had no typical classical manifestations of TSC such as seizures, mental retardation, skin lesions, or a family history of TSC. Our patient is now under routine follow-up with no medication, and is asymptomatic.", + "fulltext_subclaims": [ + "The patient is a 51-year-old Japanese woman.", + "She presented to the facility for her regular physical examination.", + "Chest radiographs showed pleural wall thickening on the right side of the apex and upper lung field.", + "The pleural wall thickening had been seen for several years on her annual regular examinations.", + "She had a mild dry cough for two weeks.", + "She had no symptoms of a common cold such as sore throat and fever.", + "She was a smoker (20 cigarettes per day for 20 years).", + "She had no history of lung disease, such as bacterial pneumonia or pulmonary tuberculosis.", + "A chest high-resolution CT scan showed multiple nodular lesions (mostly GGOs) throughout the lung fields.", + "The nodular lesions were approximately 1cm or less in diameter.", + "The nodular lesions were not detected on chest radiographs.", + "No cystic lesions, pleural effusions, or mediastinal lymph node swellings were observed.", + "Bone sclerosis lesions were detected at Th3, Th6, and the first costal bone.", + "The findings on the right side of the upper lung fields on chest radiographs were evaluated as old inflammatory changes.", + "The etiology of the old inflammatory changes seemed to be different from the multiple nodular GGOs.", + "The differential diagnoses of the lung GGOs were atypical adenomatous hyperplasia (AAH), highly differentiated adenocarcinoma in situ (AIS), lymphoproliferative disease, and MMPH.", + "Her physical findings were normal.", + "Breath sounds were normal, and no rales were heard on chest auscultation.", + "No skin lesions such as facial angiofibroma and hypomelanotic macules were observed.", + "A neurological examination showed no abnormalities.", + "She had no intellectual disability and no history of epilepsy or other diseases.", + "There was no family history of TSC.", + "There were no abnormal laboratory test results at the time of her first visit.", + "Arterial blood gas analysis results were also normal.", + "Pulmonary function tests were normal except for a mild decrease in diffusing capacity for carbon monoxide (DLCO).", + "Video-assisted thoracoscopic biopsies of the left upper lobe (S5) and the left lower lobe (S9) were performed.", + "The lesions were found to be tinged white on macroscopic examination.", + "Microscopically, the nodules were well demarcated and consisted of papillary growths of hyperplastic type II pneumocytes.", + "The nodules showed nuclear inclusion bodies and fibrous thickening of alveolar septa.", + "The nodules showed increased elastic fibers, resulting in the collapse of the alveolar space.", + "Elastica van Gieson staining revealed increased elastic tissue fibers in the lesions.", + "No cystic lesions were detected.", + "Human Melanoma Black (HMB)-45-positive cells were not observed on immunohistochemical staining.", + "These histological findings were consistent with MMPH.", + "A subsequent CT scan suggested bilateral renal angiomyolipomas.", + "Brain MRI demonstrated multiple high intensity areas of cortical and subcortical tubers.", + "All of these findings, including bone, kidney, and brain manifestations, are typical features of TSC.", + "The latter two findings are major diagnostic criteria for TSC.", + "The patient was diagnosed as having TSC with MMPH.", + "She had no typical classical manifestations of TSC such as seizures, mental retardation, skin lesions, or a family history of TSC.", + "The patient is now under routine follow-up with no medication.", + "The patient is asymptomatic." + ], + "summary": "A chest computed tomography scan of a 51-year-old Japanese woman showed multiple nodular ground-glass opacities that were not seen on chest X-ray. Video-assisted thoracoscopic surgery was performed. A histological examination demonstrated type II pneumocyte hyperplasia with thickened fibrotic alveolar septa, which was consistent with multifocal micronodular pneumocyte hyperplasia. Brain magnetic resonance imaging displayed multiple cortical tubers, and abdominal computed tomography showed bilateral renal angiomyolipoma. Our patient was finally diagnosed as having tuberous sclerosis complex with multifocal micronodular pneumocyte hyperplasia, although she had no episodes of epilepsy, no skin lesions, and no family history.", + "summary_subclaims": [ + "A chest computed tomography scan of a 51-year-old Japanese woman showed multiple nodular ground-glass opacities.", + "The multiple nodular ground-glass opacities were not seen on chest X-ray.", + "Video-assisted thoracoscopic surgery was performed.", + "A histological examination demonstrated type II pneumocyte hyperplasia with thickened fibrotic alveolar septa.", + "The histological findings were consistent with multifocal micronodular pneumocyte hyperplasia.", + "Brain magnetic resonance imaging displayed multiple cortical tubers.", + "Abdominal computed tomography showed bilateral renal angiomyolipoma.", + "The patient was finally diagnosed as having tuberous sclerosis complex with multifocal micronodular pneumocyte hyperplasia.", + "She had no episodes of epilepsy.", + "She had no skin lesions.", + "She had no family history." + ] + }, + { + "id": "multiclinsum_test_3395_en.txt", + "fulltext": "A 75-year-old man with body mass index of 30.5 kg/m2, severe OSA (apnea-hypopnea index [AHI] of 72 events/h) and Epworth Sleepiness Scale of 7 was referred for UAS therapy. He had difficulty adhering to CPAP treatment, which he was unable to tolerate due to sleep disruption. Past medical history was significant for cardiovascular disease, including congestive heart failure due to ischemic cardiomyopathy with impaired left ventricular function and ejection fraction of 35% by echocardiography. In addition, he had persistent atrial fibrillation and had received an implantable defibrillator 4 years previously, following atrioventricular node ablation. His functional status was New York Heart Association Class III. His preoperative AHI (72 events/h) was outside of the standard recommendations for UAS. However, given his failure to adhere to conservative measures, cardiovascular risk of untreated sleep apnea, and anatomic candidacy for UAS on drug-induced sleep endoscopy, he was deemed to be an appropriate candidate for UAS in an off-label indication outside of standard criteria. He underwent uncomplicated implantation.2\n\nThree months postoperatively, the patient and his bed partner reported no sleep apnea events. He described his sleep as “more refreshing” and reported overall improvement in quality of sleep and daytime fatigue. His body mass index had not changed. Polysomnography showed a titrated AHI of 0 events/h at 1.8 V and 4% oxygen desaturation index of 1.5. He further titrated his device to 2 V at a bipolar (+-+) configuration and had a repeat 2-night home sleep study 2 months later showing 4% respiratory event index of 3.9 and 2.3 events/h on respective nights. At 1-year follow-up, the patient reported continuous improvement in quality of sleep with usage of the device at 2 V. Cardiac evaluation revealed that ejection fraction had increased to 47% since implantation and chronic anemia had resolved. Functional class had improved to New York Heart Association Class I. No interval change in his medical management had occurred.", + "fulltext_subclaims": [ + "The patient is a 75-year-old man.", + "The patient has a body mass index of 30.5 kg/m2.", + "The patient has severe OSA with an apnea-hypopnea index of 72 events/h.", + "The patient's Epworth Sleepiness Scale score is 7.", + "The patient had difficulty adhering to CPAP treatment.", + "The patient was unable to tolerate CPAP due to sleep disruption.", + "The patient has congestive heart failure due to ischemic cardiomyopathy.", + "The patient's left ventricular ejection fraction is 35% by echocardiography.", + "The patient has persistent atrial fibrillation.", + "The patient had an implantable defibrillator placed 4 years previously.", + "The implantable defibrillator was placed following atrioventricular node ablation.", + "The patient's functional status is New York Heart Association Class III.", + "The patient's preoperative AHI was 72 events/h.", + "The patient's preoperative AHI was outside of the standard recommendations for UAS.", + "The patient was deemed an appropriate candidate for UAS in an off-label indication.", + "The patient underwent uncomplicated implantation.", + "Three months postoperatively, the patient reported no sleep apnea events.", + "Three months postoperatively, the patient described his sleep as 'more refreshing'.", + "Three months postoperatively, the patient reported overall improvement in quality of sleep.", + "Three months postoperatively, the patient reported improvement in daytime fatigue.", + "Three months postoperatively, the patient's body mass index had not changed.", + "Polysomnography showed a titrated AHI of 0 events/h at 1.8 V.", + "Polysomnography showed a 4% oxygen desaturation index of 1.5.", + "The patient titrated his device to 2 V at a bipolar (+-+) configuration.", + "A 2-night home sleep study 2 months later showed a 4% respiratory event index of 3.9.", + "A 2-night home sleep study 2 months later showed 2.3 events/h on the second night.", + "At 1-year follow-up, the patient reported continuous improvement in quality of sleep.", + "At 1-year follow-up, the patient used the device at 2 V.", + "Cardiac evaluation at 1 year showed an ejection fraction of 47%.", + "Chronic anemia had resolved at 1-year follow-up.", + "Functional class had improved to New York Heart Association Class I.", + "No interval change in medical management had occurred." + ], + "summary": "A 75-year-old man with body mass index of 30.5 kg/m2 and severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 72 events/h was referred for upper airway stimulation (UAS) therapy. Past medical history was significant for cardiovascular disease including congestive heart failure due to ischemic cardiomyopathy with impaired left ventricular function and ejection fraction of 35%. Following evaluation of clinical and polysomnographic data, he was an appropriate candidate for UAS and underwent uncomplicated implantation. Three months postoperatively, polysomnography showed a titrated AHI of 0 events/h. Follow-up cardiac evaluation revealed ejection fraction increase to 47% since implantation. No interval change in medical management or body mass index had occurred.", + "summary_subclaims": [ + "The patient is a 75-year-old man.", + "The patient has a body mass index of 30.5 kg/m2.", + "The patient has severe obstructive sleep apnea.", + "The patient's apnea-hypopnea index was 72 events/h.", + "The patient was referred for upper airway stimulation therapy.", + "The patient has cardiovascular disease.", + "The patient has congestive heart failure due to ischemic cardiomyopathy.", + "The patient's ejection fraction was 35%.", + "The patient was an appropriate candidate for upper airway stimulation.", + "The patient underwent uncomplicated implantation.", + "Three months postoperatively, polysomnography showed a titrated AHI of 0 events/h.", + "Follow-up cardiac evaluation revealed ejection fraction increase to 47% since implantation.", + "No interval change in medical management had occurred.", + "No interval change in body mass index had occurred." + ] + }, + { + "id": "multiclinsum_test_1290_en.txt", + "fulltext": "A 51-year-old man with a history of atrial fibrillation (AF) presented to the emergency department with acute onset of the left-sided weakness 45 min after his last known well (LNW). Further, anamnesis revealed that in the past 6th month, he did not take oral anticoagulation for his AF. The baseline National Institutes of Health Stroke Scale (NIHSS) score was 14, with left hemiplegia, right conjugate eye deviation, dysarthria, and facial paralysis. On initial examination, the patient was afebrile and alert with a Glasgow Coma Score (GCS) of 15, blood pressure was 140/67 mmHg, and his respiratory rate was 20 breaths/ min. In addition to that, his pulse was low, around 36 beats/ min. The electrocardiogram revealed a junctional rhythm. Sulfas atropine and dopamine were administered to treat the bradycardia since the pulse decreased to 20 beats/min and GCS dropped to 11 (E3V3M5). After hemodynamic stabilization, a head non-contrast computed tomography (NCCT) was performed (i.e., 2 h after LNW). A head NCCT revealed a hyperdense right middle cerebral artery (MCA) sign, suggesting a hyperacute thrombotic stroke . All the laboratory studies were within a normal limit.\nAt 4 h after LNW, the patient received IVT using recombinant tissue plasminogen activator (alteplase) (r-tPA). Under General anesthesia, he was taken for temporary pacemaker (TPM) insertion by cardiologist, followed by EVT by our endovascular surgeon. An angiogram of the right internal carotid artery at hour 6 confirmed occlusion of the M1 branch of the right MCA with no collaterals in the territory of the occluded vessel . The first attempt of manual aspiration thrombectomy successfully achieved modified thrombolysis in cerebral infarction 3 revascularization in 6 h 20 min . The occlusive thrombus was all removed using the direct aspiration first pass technique with a catheter aspiration system.\nPost-thrombectomy, the patient was still intubated and sedated. During observation in the intensive care unit, he developed an occasional premature ventricular contraction and upside-down blood pressure. Follow-up NCCT within 24 h following thrombectomy revealed petechial hemorrhage on the infarcted area and massive focal brain edema on the right frontotemporoparietal, resulting in a 13-mm midline shift (MLS).\nThe patient was treated conservatively initially for his brain edema. After being given conservative treatment for 2 days, the patient was not on sedation but still unconscious with GCS of E2V × M5. He developed anisocoria pupils with diameters of 2 mm and 1 mm, on the right and left pupils, respectively. The diagnosis of MBE was made, and the patient was taken for emergent decompressive craniectomy (DC) to release the intracranial pressure.\nTwo days following DC, the patient was allowed to awaken to the point where a limited neurologic examination was possible and subsequently extubated. He could move all four extremities on command but still had left hemiparesis, and his pupils were isochor. His NIHSS score was 6 for left hemiparesis and dysarthria. Follow-up NCCT was performed 4 days after DC and revealed decreased mass effect to 6 mm MLS. The TPM was changed into permanent pace maker after 7 days of its insertion . The patient was discharged home on hospitalization day 15. The Modified Rankin scale score was four in 1- and 3-month’s follow-up.", + "fulltext_subclaims": [ + "The patient is a 51-year-old man with a history of atrial fibrillation.", + "He presented with acute onset of left-sided weakness 45 min after his last known well.", + "In the past 6th month, he did not take oral anticoagulation for his AF.", + "The baseline NIHSS score was 14.", + "The patient was afebrile and alert with a GCS of 15.", + "His blood pressure was 140/67 mmHg.", + "His respiratory rate was 20 breaths/min.", + "His pulse was low, around 36 beats/min.", + "The electrocardiogram revealed a junctional rhythm.", + "Sulfas atropine and dopamine were administered.", + "A head NCCT was performed 2 h after LNW.", + "The head NCCT revealed a hyperdense right MCA sign.", + "The hyperdense right MCA sign suggests a hyperacute thrombotic stroke.", + "All the laboratory studies were within a normal limit.", + "The patient received IVT using alteplase at 4 h after LNW.", + "He was taken for temporary pacemaker insertion by a cardiologist.", + "He was taken for EVT by an endovascular surgeon.", + "An angiogram at hour 6 confirmed occlusion of the M1 branch of the right MCA.", + "The first attempt of manual aspiration thrombectomy achieved mTICI 3 revascularization.", + "The occlusive thrombus was all removed using the direct aspiration first pass technique.", + "Post-thrombectomy, the patient was intubated and sedated.", + "He developed an occasional premature ventricular contraction.", + "He developed upside-down blood pressure.", + "Follow-up NCCT within 24 h revealed petechial hemorrhage on the infarcted area.", + "Follow-up NCCT within 24 h revealed massive focal brain edema on the right frontotemporoparietal.", + "The follow-up NCCT revealed a 13-mm midline shift.", + "The patient was treated conservatively initially for his brain edema.", + "After 2 days of conservative treatment, the patient was not on sedation.", + "He was still unconscious with a GCS of E2V × M5.", + "He developed anisocoria pupils with diameters of 2 mm and 1 mm.", + "The diagnosis of MBE was made.", + "The patient was taken for emergent decompressive craniectomy.", + "Two days following DC, the patient was allowed to awaken.", + "He could move all four extremities on command.", + "He still had left hemiparesis.", + "His pupils were isochor.", + "His NIHSS score was 6 for left hemiparesis and dysarthria.", + "Follow-up NCCT 4 days after DC revealed decreased mass effect to 6 mm MLS.", + "The TPM was changed into a permanent pacemaker after 7 days.", + "The patient was discharged home on hospitalization day 15.", + "The Modified Rankin scale score was four in 1- and 3-month follow-up." + ], + "summary": "A 51-year-old man with a history of atrial fibrillation presented with acute onset of hemiplegia and severe bradyarrhythmia. A head computed tomography-scan demonstrated hyperdense middle cerebral artery (MCA) sign. Intravenous thrombolysis was administered before temporary pacemaker insertion. The digital subtraction angiography confirmed occlusion of the M1 branch of the right MCA with no collaterals in the territory of the occluded vessel. Mechanical thrombectomy (MT) was performed 6 h after onset and successfully achieved modified thrombolysis in cerebral infarction 3 revascularization in 6 h 20 min. The patient later experienced massive brain edema that required emergent decompressive craniectomy. The modified Rankin scale score was 4 in 1- and 3-month's follow-up.", + "summary_subclaims": [ + "The patient is a 51-year-old man.", + "The patient has a history of atrial fibrillation.", + "The patient presented with acute onset of hemiplegia.", + "The patient presented with severe bradyarrhythmia.", + "A head computed tomography-scan demonstrated hyperdense middle cerebral artery sign.", + "Intravenous thrombolysis was administered.", + "The digital subtraction angiography confirmed occlusion of the M1 branch of the right middle cerebral artery.", + "The digital subtraction angiography showed no collaterals in the territory of the occluded vessel.", + "Mechanical thrombectomy was performed 6 h after onset.", + "Mechanical thrombectomy achieved modified thrombolysis in cerebral infarction 3 revascularization.", + "Mechanical thrombectomy was performed in 6 h 20 min.", + "The patient later experienced massive brain edema.", + "Emergent decompressive craniectomy was required.", + "The modified Rankin scale score was 4 at 1-month follow-up.", + "The modified Rankin scale score was 4 at 3-month follow-up." + ] + }, + { + "id": "multiclinsum_test_1689_en.txt", + "fulltext": "A 23-year-old male patient came to the emergency department at Universitas Airlangga Hospital presenting fever, anosmia, headache, and nausea 5 days before. He was diagnosed with COVID-19, confirmed by the RT-PCR amplification of SARS-CoV-2 virus nucleic acid on a nasopharyngeal swab. The patient had abnormal laboratory findings, such as lymphopenia, neutrophilia, thrombocytopenia, and high CRP, with a normal chest X-ray . The patient was treated with Favipiravir at 1600 mg per 12 h on day 1, then 600 mg per 12 h on day 2-day 5, intravenous drip of paracetamol 1000 mg every 8 h, oral vitamin C 500 mg per 8 h, and oral vitamin D 1000 IU per day according to Indonesian national COVID-19 treatment guidelines. After 10 days of treatment, the patient was still PCR positive despite no complaints. He was then discharged to continue self-quarantine at home.\nHe returned to the hospital two weeks later with general weakness and fever. The fever did not resolve during his self-quarantine, was raised intermittently every 2 days, and was marked by a chilling-fever-sweating cycle. The fever temperature measured was around 39.7°–40 °C. The fever improved when the patient took paracetamol, but the fever returned 6 h later. The fever was accompanied by malaise and muscle pain. The next day the patient was fever-free and able to carry out his daily activities. The physical examination revealed a body temperature of 38 °C, a blood pressure of 112/72 mmHg, a heart rate of 93 bpm, a respiratory rate of 20 breaths/minute, and oxygen saturation of 98% under ambient air. The patient weighs 65 kg with a height of 170 cm (BMI 22.5 kg/m2). Other physical examinations were normal.\nThe laboratory results reflected a white blood cell count of 8750/µL with 76.3% neutrophils, 13.5% lymphocytes, and 0.6% eosinophils. Haemoglobin level and platelet counts were 12.2 g/dL and 231,000/µL, respectively. CRP and D-dimer levels were 41.51 mg/L and 9.52 mg/L, respectively. Serum electrolytes and renal function tests were normal, with urea and creatinine serum 6 mg/dL and 0.4 mg/dL, respectively. The liver enzymes test was normal, with ALT being 14 IU/L and AST being 25 IU/L. Electrocardiography showed normal sinus rhythm and axis. The chest X-ray was unremarkable . The RT-PCR amplification of the SARS-CoV-2 virus nucleic acid test from the nasopharyngeal swab was still positive.\nFrom the previous history, he said that he traveled to Timika District, Papua, for office work for the last 2 years. In May 2021, the patient was infected with P vivax, with initial symptoms including fever, dizziness, nausea, and muscle pain. The patient was treated until declared fully cured. A laboratory test for malaria was performed. The rapid malaria test was positive for PAN antigen, and microscopic diagnosis on blood smear revealed Plasmodium vivax on ring form, trophozoite, and gametocyte stage . Based on anamnesis, physical examination, and laboratory results, the patient was diagnosed with confirmed COVID-19 with hypercoagulopathy and malaria vivax relapse . According to Indonesian National Guidelines for Antimalarial Treatment , he was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days and primaquine 2 tablets per day for 14 days. The G6PD status was not tested. The patient was given an intravenous drip of paracetamol 1000 mg every 8 h and a subcutaneous injection of heparin 5000 IU every 12 h during treatment. After six days of treatment, the patient had no complaints, and the results of laboratory tests had improved. The patient was discharged from the hospital, continued self-isolation at home, and followed up with the internal medicine outpatient clinic two weeks later. Furthermore, the patient was called later and reported feeling healthy with no complaints.", + "fulltext_subclaims": [ + "The patient is a 23-year-old male.", + "He presented to the emergency department at Universitas Airlangga Hospital.", + "He had fever, anosmia, headache, and nausea 5 days before presentation.", + "He was diagnosed with COVID-19.", + "The diagnosis was confirmed by RT-PCR amplification of SARS-CoV-2 virus nucleic acid on a nasopharyngeal swab.", + "The patient had lymphopenia.", + "The patient had neutrophilia.", + "The patient had thrombocytopenia.", + "The patient had high CRP.", + "The chest X-ray was normal.", + "The patient was treated with Favipiravir at 1600 mg per 12 h on day 1.", + "The patient was treated with Favipiravir at 600 mg per 12 h on day 2–day 5.", + "The patient received intravenous drip of paracetamol 1000 mg every 8 h.", + "The patient received oral vitamin C 500 mg per 8 h.", + "The patient received oral vitamin D 1000 IU per day.", + "The treatment was according to Indonesian national COVID-19 treatment guidelines.", + "After 10 days of treatment, the patient was still PCR positive.", + "The patient had no complaints after 10 days of treatment.", + "The patient was discharged to continue self-quarantine at home.", + "He returned to the hospital two weeks later.", + "He had general weakness and fever.", + "The fever was raised intermittently every 2 days.", + "The fever was marked by a chilling-fever-sweating cycle.", + "The fever temperature measured was around 39.7°–40 °C.", + "The fever improved when the patient took paracetamol.", + "The fever returned 6 h after taking paracetamol.", + "The fever was accompanied by malaise and muscle pain.", + "The next day the patient was fever-free.", + "The next day the patient was able to carry out his daily activities.", + "The physical examination revealed a body temperature of 38 °C.", + "The physical examination revealed a blood pressure of 112/72 mmHg.", + "The physical examination revealed a heart rate of 93 bpm.", + "The physical examination revealed a respiratory rate of 20 breaths/minute.", + "The physical examination revealed oxygen saturation of 98% under ambient air.", + "The patient weighs 65 kg.", + "The patient is 170 cm tall.", + "The chest X-ray was unremarkable.", + "The RT-PCR amplification of the SARS-CoV-2 virus nucleic acid test from the nasopharyngeal swab was still positive.", + "The patient had traveled to Timika District, Papua, for office work for the last 2 years.", + "In May 2021, the patient was infected with P vivax.", + "The initial symptoms included fever, dizziness, nausea, and muscle pain.", + "The patient was treated until declared fully cured.", + "A laboratory test for malaria was performed.", + "The rapid malaria test was positive for PAN antigen.", + "Microscopic diagnosis on blood smear revealed Plasmodium vivax on ring form, trophozoite, and gametocyte stage.", + "The patient was diagnosed with confirmed COVID-19 with hypercoagulopathy and malaria vivax relapse.", + "He was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days.", + "He was treated with primaquine 2 tablets per day for 14 days.", + "The G6PD status was not tested.", + "The patient was given an intravenous drip of paracetamol 1000 mg every 8 h.", + "The patient was given a subcutaneous injection of heparin 5000 IU every 12 h.", + "After six days of treatment, the patient had no complaints.", + "The results of laboratory tests had improved.", + "The patient was discharged from the hospital.", + "The patient continued self-isolation at home.", + "The patient was followed up with the internal medicine outpatient clinic two weeks later.", + "The patient reported feeling healthy with no complaints." + ], + "summary": "A 23-year-old male patient presented to the hospital with fever, anosmia, headache, and nausea 1 week before. He was diagnosed with COVID-19 and treated for approximately 10 days, then discharged to continue self-quarantine at home. 2 weeks later, he returned to the hospital with a fever raised intermittently every 2 days and marked by a chilling-fever-sweating cycle. A laboratory test for malaria and a nasopharyngeal swab for SARS CoV-2 PCR were conducted, confirming both diagnoses. The laboratory examination showed markedly elevated D-dimer. He was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days and primaquine 2 tablets per day for 14 days according to Indonesian National Anti-malarial Treatment Guidelines. After 6 days of treatment, the patient had no complaints, and the results of laboratory tests had improved. This report describes the key points in considering the differential diagnosis and prompt treatment of malaria infection during the pandemic of COVID-19 in an endemic country to prevent the worse clinical outcomes. COVID-19 and malaria may also cause a hypercoagulable state, so a co-infection of those diseases may impact the prognosis of the disease.", + "summary_subclaims": [ + "The patient is a 23-year-old male.", + "The patient presented to the hospital with fever, anosmia, headache, and nausea 1 week before.", + "He was diagnosed with COVID-19.", + "He was treated for approximately 10 days.", + "He was discharged to continue self-quarantine at home.", + "2 weeks later, he returned to the hospital with a fever raised intermittently every 2 days.", + "The fever was marked by a chilling-fever-sweating cycle.", + "A laboratory test for malaria was conducted.", + "A nasopharyngeal swab for SARS CoV-2 PCR was conducted.", + "Both diagnoses were confirmed.", + "The laboratory examination showed markedly elevated D-dimer.", + "He was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days.", + "He was treated with primaquine 2 tablets per day for 14 days.", + "The treatment was according to Indonesian National Anti-malarial Treatment Guidelines.", + "After 6 days of treatment, the patient had no complaints.", + "The results of laboratory tests had improved.", + "This report describes the key points in considering the differential diagnosis and prompt treatment of malaria infection during the pandemic of COVID-19 in an endemic country.", + "The purpose is to prevent worse clinical outcomes.", + "Co-infection of COVID-19 and malaria may impact the prognosis of the disease." + ] + }, + { + "id": "multiclinsum_test_37_en.txt", + "fulltext": "A 63-year-old myopic female with exfoliation glaucoma presented with a visually significant cataract in the right eye. The best corrected visual acuity (BCVA) was 20/60 and IOP was 20 mm Hg on Latanoprost. Her untreated IOP was 25 mm Hg. The right eye had a cup to a disc of 0.6, with an axial length of 26.42 mm and an AC depth of 3.43 mm. She had a grade 3 angle open to scleral spur with 3+ TM pigmentation. She elected to have cataract surgery with a femtosecond laser and wanted vision correction at all distances, so the decision was made to perform FLACS with a trifocal IOL (Panoptix, Alcon, Ft. Worth, TX, USA), Given that her angle was open and her IOP was slightly elevated, she was a candidate for angle based MIGS. The decision was made to perform trabectome (Microsurgical Technology, Redmond, WA, USA) in combination with cataract surgery. Past medical history included hypothyroidism and hyperlipidemia. She had no other medical conditions, was not on anticoagulation therapy, and did not have any coagulation disorder.\nThe capsulorhexis, nuclear divisions, and an arcuate incision were performed using the Catalys Precision Laser System (Johnson and Johnson, New Brunswick, NJ, USA) and there was no bleeding. She was then brought from the femtosecond laser room to the operating room for the manual portion of the surgery. A temporal paracentesis and temporal main wound were created, followed by injection of dispersive viscoelastic. Preparation for the trabectome was made by tilting the head and microscope. Upon placing the gonioprism, the angle was noted to be open, with a heavily pigmented TM and no blood noted in the Schlemms canal . The trabectome was placed into the AC and was performed, ablating and removing 90 degrees of the TM. Upon completion of the trabectome, there was a copious amount of bleeding from the nasal angle incision. Additional dispersive viscoelastic was injected into the nasal angle to tamponade the bleeding.\nThe manual portion of the cataract surgery commenced. The head was tilted back to the ortho position and the microscope was positioned. The capsulorhexis was removed and phacoemulsification was performed. During the cataract surgery, there continued to be bleeding from the angle, for which more dispersive viscoelastic was injected into the angle to try to stop the bleeding. The blood was removed with irrigation and aspiration during the phacoemulsification and cortical clean-up. The intraocular lens was implanted. After the lens was injected and viscoelastic was removed, there was still a large amount of blood emanating from the angle. AC washout was performed with irrigation and aspiration and more dispersive viscoelastic was injected to tamponade the bleeding. The bleeding continued, so the decision was made to use a needle tip cautery to achieve hemostasis. The microscope was tilted, the head was rotated and with the assistance of a surgical gonioprism, cautery was applied to the bleeding area of the angle. Additional washout was performed and more dispersive viscoelastic was injected to tamponade the bleeding. The bleeding improved and the surgery was completed. Dispersive viscoelastic was retained in the eye to continue to serve as tamponade. Head of bed elevation and no straining were advised.\nOn postoperative day 1, the vision was hand motions with IOP 49 mm Hg. The AC had a 7 mm hyphema with 4+ microhyphema. B-scan ultrasound showed no vitreoretinal pathology. The paracentesis was tapped until the IOP decreased to 6 mm Hg. She was started on timolol-brimonidine and netarsudil in the right eye in addition to moxifloxacin, prednisolone, and ketorolac. The latanoprost was discontinued.\nOn postoperative day 2, the vision was hand motions and the IOP was 44 mm Hg. The AC had 2 mm of layered hyphema and 4+ microhyphema. There was no area of active bleeding. The paracentesis tap was repeated until the IOP was 24 mm Hg. On postoperative day 3, the vision was hand motions and the IOP was 21 mm Hg. The AC had 1.5 mm of layered hyphema with 4+ microhyphema and a nasal blood clot . She was followed daily with improving hyphema and stable IOP. There was a rebleed on postoperative day 7 with an IOP increase to 51 mm Hg. An AC washout was considered, but the decision was made to continue with office-based management due to the possibility of continued bleeding with a surgical AC washout. A paracentesis was made, and wound tapping was repeated. The IOP stabilized on postoperative day 8 and onwards with resolving hyphema.\nOn postoperative day 18, the vision improved to 20/70, IOP was 13 mm Hg, and there were no clots or layered hyphema. There was remaining 4+ microhyphema. By postoperative month 1, the microhyphema had cleared, but there was an endocapsular hematoma present . An Nd:YAG posterior capsulotomy was performed successfully. On the postsurgery month 9 visit, visual acuity was 20/25 with IOP 15 mm Hg on Brimonidine once daily.", + "fulltext_subclaims": [ + "The patient is a 63-year-old myopic female with exfoliation glaucoma.", + "She presented with a visually significant cataract in the right eye.", + "The best corrected visual acuity (BCVA) was 20/60.", + "The IOP was 20 mm Hg on Latanoprost.", + "Her untreated IOP was 25 mm Hg.", + "The right eye had a cup to disc ratio of 0.6.", + "The axial length was 26.42 mm.", + "The anterior chamber depth was 3.43 mm.", + "She had a grade 3 angle open to scleral spur.", + "She had 3+ trabecular meshwork pigmentation.", + "She elected to have cataract surgery with a femtosecond laser.", + "She wanted vision correction at all distances.", + "The decision was made to perform FLACS with a trifocal IOL (Panoptix, Alcon).", + "She was a candidate for angle-based MIGS.", + "The decision was made to perform trabectome in combination with cataract surgery.", + "Past medical history included hypothyroidism and hyperlipidemia.", + "She had no other medical conditions.", + "She was not on anticoagulation therapy.", + "She did not have any coagulation disorder.", + "The capsulorhexis, nuclear divisions, and an arcuate incision were performed using the Catalys Precision Laser System.", + "There was no bleeding during the femtosecond laser portion.", + "She was brought to the operating room for the manual portion of the surgery.", + "A temporal paracentesis and temporal main wound were created.", + "Dispersive viscoelastic was injected.", + "The angle was noted to be open with a heavily pigmented trabecular meshwork.", + "No blood was noted in Schlemm's canal.", + "The trabectome was placed into the anterior chamber.", + "The trabectome was performed, ablating and removing 90 degrees of the trabecular meshwork.", + "There was a copious amount of bleeding from the nasal angle incision.", + "Additional dispersive viscoelastic was injected into the nasal angle to tamponade the bleeding.", + "The manual portion of the cataract surgery commenced.", + "The capsulorhexis was removed.", + "Phacoemulsification was performed.", + "There continued to be bleeding from the angle during the cataract surgery.", + "More dispersive viscoelastic was injected into the angle to try to stop the bleeding.", + "The blood was removed with irrigation and aspiration during the phacoemulsification and cortical clean-up.", + "The intraocular lens was implanted.", + "After the lens was injected and viscoelastic was removed, there was still a large amount of blood emanating from the angle.", + "AC washout was performed with irrigation and aspiration.", + "More dispersive viscoelastic was injected to tamponade the bleeding.", + "The decision was made to use a needle tip cautery to achieve hemostasis.", + "Cautery was applied to the bleeding area of the angle.", + "Additional washout was performed.", + "More dispersive viscoelastic was injected to tamponade the bleeding.", + "The bleeding improved and the surgery was completed.", + "Dispersive viscoelastic was retained in the eye to continue to serve as tamponade.", + "Head of bed elevation and no straining were advised.", + "On postoperative day 1, the vision was hand motions.", + "The IOP was 49 mm Hg on postoperative day 1.", + "The anterior chamber had a 7 mm hyphema with 4+ microhyphema.", + "B-scan ultrasound showed no vitreoretinal pathology.", + "The paracentesis was tapped until the IOP decreased to 6 mm Hg.", + "She was started on timolol-brimonidine and netarsudil in the right eye.", + "She was started on moxifloxacin, prednisolone, and ketorolac.", + "The latanoprost was discontinued.", + "On postoperative day 2, the vision was hand motions.", + "The IOP was 44 mm Hg on postoperative day 2.", + "The anterior chamber had 2 mm of layered hyphema with 4+ microhyphema.", + "There was no area of active bleeding.", + "The paracentesis tap was repeated until the IOP was 24 mm Hg.", + "On postoperative day 3, the vision was hand motions.", + "The IOP was 21 mm Hg on postoperative day 3.", + "The anterior chamber had 1.5 mm of layered hyphema with 4+ microhyphema.", + "There was a nasal blood clot.", + "She was followed daily with improving hyphema and stable IOP.", + "There was a rebleed on postoperative day 7.", + "The IOP increased to 51 mm Hg.", + "An AC washout was considered.", + "The decision was made to continue with office-based management.", + "A paracentesis was made.", + "Wound tapping was repeated.", + "The IOP stabilized on postoperative day 8.", + "The hyphema resolved.", + "On postoperative day 18, the vision improved to 20/70.", + "The IOP was 13 mm Hg.", + "There were no clots or layered hyphema.", + "There was remaining 4+ microhyphema.", + "By postoperative month 1, the microhyphema had cleared.", + "There was an endocapsular hematoma present.", + "An Nd:YAG posterior capsulotomy was performed successfully.", + "On the postsurgery month 9 visit, visual acuity was 20/25.", + "The IOP was 15 mm Hg.", + "The patient was on Brimonidine once daily." + ], + "summary": "A 63-year-old myopic female with exfoliation glaucoma underwent FLACS with a trifocal intraocular lens implant and Trabectome in the right eye. Significant intraoperative bleeding ensued following the trabectome and was treated with viscoelastic tamponade, anterior chamber (AC) washout, and cautery. The patient developed a large hyphema with intraocular pressure (IOP) rise that was treated with multiple AC taps, paracentesis, and eye drops. The hyphema took approximately 1 month to completely clear, leaving an endocapsular hematoma. This was treated successfully with Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser posterior capsulotomy.", + "summary_subclaims": [ + "The patient is a 63-year-old myopic female.", + "The patient has exfoliation glaucoma.", + "The patient underwent FLACS with a trifocal intraocular lens implant and Trabectome in the right eye.", + "Significant intraoperative bleeding ensued following the trabectome.", + "The intraoperative bleeding was treated with viscoelastic tamponade.", + "The intraoperative bleeding was treated with anterior chamber washout.", + "The intraoperative bleeding was treated with cautery.", + "The patient developed a large hyphema.", + "The patient had an intraocular pressure rise.", + "The hyphema was treated with multiple anterior chamber taps.", + "The hyphema was treated with paracentesis.", + "The hyphema was treated with eye drops.", + "The hyphema took approximately 1 month to completely clear.", + "An endocapsular hematoma was left after the hyphema cleared.", + "The endocapsular hematoma was treated with Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser posterior capsulotomy." + ] + }, + { + "id": "multiclinsum_test_1058_en.txt", + "fulltext": "A 26-year-old Chinese man with a chief complaint of a mass in the right submandibular region for the past 1 year was admitted to Xiangya Hospital, Central South University, Hunan, China. He had no significant past medical or family history. Routine physical and laboratory examinations were performed. Ultrasonography revealed a hypoechoic mass measuring approximately 28 mm × 18 mm in the right submandibular region, with an irregular shape and clear boundary . Abdominal computed tomography (CT) scan revealed no other lesion. There was no evidence of metastasis to the local or distant organs. Hence, lumpectomy was performed under general anesthesia.\nHistological examination showed sheets, cords, and nests of small round cells separated focally by desmoplastic stroma . Under higher magnification, tumor cells showed round to oval hyperchromatic nuclei with an increased nuclear/cytoplasmic ratio and inconspicuous nucleoli. The cytoplasm of the tumor cells was scanty with indistinct cytoplasmic borders . Mitotic activity and individual cell necrosis were common. Immunohistochemical analysis was performed using formalin-fixed paraffin embedded sections from representative tumor blocks and the antibodies listed in Table . Immunohistochemical results indicated the multi-directional differentiation of tumor cells. The immunohistochemistry results were as follows: desmin (+) , FLI-1 (+), CD99 (+), E-cadherinD (+), chromogranin-A (+), neuron-specific enolase (+), vimentin (+) , pan-cytokeratin (+), epithelial membrane antigen (+), CD56 (+), synaptophysin (weakly positive [+/−]), NKX2.2 (−), WT1 (−), myogenin (−), and S-100 (−). Moreover, the Ki-67 proliferation index was estimated as 50%. The tumor cells were negative for Epstein-Barr virus-encoded small RNA on fluorescence in situ hybridization (FISH). The FISH analysis with a break-apart probe proved that there was EWSR1 gene spilt in the neoplastic cells . However, EWSR1-WT1 fusion detection by reverse transcription-polymerase chain reaction was not performed owing to certain limitations. Based on the above findings, primary lesions in the abdominal cavity and pelvic cavity were excluded, and a final diagnosis of primary DSRCT in the submandibular gland was made.\nComprehensive anti-tumor therapy mainly based on chemotherapy and radiotherapy was first proposed. However, synchronous chemotherapy was not performed owing to the risk of bone marrow suppression. Therefore, cyclophosphamide combined with doxorubicin and vincristine chemotherapy was used for maintenance treatment. The patient is currently alive and well with no evidence of tumor recurrence.", + "fulltext_subclaims": [ + "A 26-year-old Chinese man with a chief complaint of a mass in the right submandibular region for the past 1 year was admitted to Xiangya Hospital, Central South University, Hunan, China.", + "He had no significant past medical or family history.", + "Ultrasonography revealed a hypoechoic mass measuring approximately 28 mm × 18 mm in the right submandibular region.", + "The mass had an irregular shape and clear boundary.", + "Abdominal computed tomography (CT) scan revealed no other lesion.", + "There was no evidence of metastasis to the local or distant organs.", + "Lumpectomy was performed under general anesthesia.", + "Histological examination showed sheets, cords, and nests of small round cells separated focally by desmoplastic stroma.", + "Tumor cells showed round to oval hyperchromatic nuclei with an increased nuclear/cytoplasmic ratio.", + "The cytoplasm of the tumor cells was scanty with indistinct cytoplasmic borders.", + "Mitotic activity and individual cell necrosis were common.", + "Immunohistochemical results indicated the multi-directional differentiation of tumor cells.", + "The immunohistochemistry results were as follows: desmin (+), FLI-1 (+), CD99 (+), E-cadherinD (+), chromogranin-A (+), neuron-specific enolase (+), vimentin (+), pan-cytokeratin (+), epithelial membrane antigen (+), CD56 (+), synaptophysin (weakly positive [+/−]), NKX2.2 (−), WT1 (−), myogenin (−), and S-100 (−).", + "The Ki-67 proliferation index was estimated as 50%.", + "The tumor cells were negative for Epstein-Barr virus-encoded small RNA on fluorescence in situ hybridization (FISH).", + "FISH analysis with a break-apart probe proved that there was EWSR1 gene split in the neoplastic cells.", + "EWSR1-WT1 fusion detection by reverse transcription-polymerase chain reaction was not performed owing to certain limitations.", + "Primary lesions in the abdominal cavity and pelvic cavity were excluded.", + "A final diagnosis of primary DSRCT in the submandibular gland was made.", + "Comprehensive anti-tumor therapy mainly based on chemotherapy and radiotherapy was first proposed.", + "Synchronous chemotherapy was not performed owing to the risk of bone marrow suppression.", + "Cyclophosphamide combined with doxorubicin and vincristine chemotherapy was used for maintenance treatment.", + "The patient is currently alive and well with no evidence of tumor recurrence." + ], + "summary": "We report a case of a 26-year-old Chinese man with a mass in the right submandibular gland. Imaging studies showed a hypoechoic mass in the right submandibular region. Intraoperative pathology revealed that the tumor tissue was composed of small round tumor cells and a dense desmoplastic stroma. On immunostaining, the tumor cells showed markers of epithelial, mesenchymal, myogenic, and neural differentiation. The EWSR1 gene rearrangement was detected by fluorescence in situ hybridization. Based on the overall morphological features and immunohistochemical findings, a final diagnosis of DSRCT was made. The patient was treated with comprehensive anti-tumor therapy mainly based on radiotherapy and chemotherapy.", + "summary_subclaims": [ + "The patient is a 26-year-old Chinese man.", + "The patient had a mass in the right submandibular gland.", + "Imaging studies showed a hypoechoic mass in the right submandibular region.", + "Intraoperative pathology revealed that the tumor tissue was composed of small round tumor cells and a dense desmoplastic stroma.", + "On immunostaining, the tumor cells showed markers of epithelial, mesenchymal, myogenic, and neural differentiation.", + "The EWSR1 gene rearrangement was detected by fluorescence in situ hybridization.", + "A final diagnosis of DSRCT was made.", + "The patient was treated with comprehensive anti-tumor therapy mainly based on radiotherapy and chemotherapy." + ] + }, + { + "id": "multiclinsum_test_774_en.txt", + "fulltext": "An 8-year-old Afghan girl presented with a two-month history of edema, abdominal distension, weakness, pallor, chills, fever, anorexia, and weight loss. Her medical history was not remarkable. Physical examinations showed severe mucosal and conjunctival pallor, periorbital and sacral edemas, and abdominal distension. She also presented with tender mobile lymph nodes in her right neck (5 × 5 mm), bilateral inguinal area (0.5 cm × 0.5 cm) and left axillary (0.7 cm × 0.7 cm), as well as marked hepatosplenomegaly and ascites with shifting dullness. Systolic murmurs (II/III) of the heart and lungs were apparent.\nIn this patient, Hodgkin's lymphoma had metastasized to the myocardial tissue. The tumor involved all the cardiac tissue and the septum. Metastasis must have occurred via the blood vessels because it involved the cardiac tissue itself as well as the lymph nodes. Other hematopoetic areas such as the liver, spleen and bone marrow were also involved.\nThe symptoms of lymphadenopathy included enlargement of the lymph nodes, in particular the para-aortic lymph nodes. There were symptoms of cardiac failure in the form of tachycardia, cardiomegaly, gallop rhythm, tachypnea, weak pulse, and hypotension.\nIn examining the patient, we used all diagnostic standards except positron emission tomography, because the patient had already been diagnosed with lymphoma and metastasis. There were no signs of Hodgkin's lymphoma in the bone marrow and bone aspiration test results.\nLaboratory findings included severe anemia with moderate anisopoikilocytosis, hemoglobin level of 3.2 (normal range 260 to 400 mg/dl), erythrocyte sedimentation rate of 50 (normal range <15 mm/hr), and positive C-reactive protein. Polymerase chain reaction for tuberculosis, blood culture, urine culture, hydatid antibody, Coombs Wright and 2 ME, direct Coombs, bone marrow culture, and blood smears for malaria and borrelia were all negative. Our patient's G6PD level was also normal.\nThere were several findings that led to the identification of appropriate treatment for our patient. In abdominal sonography, her liver was found to be enlarged with heterogenic echo. Marked hepatosplenomegaly (spans = 17 cm) and two round hypoechoic areas in the hepatic portal space due to adenopathy were seen. Her biliary gall bladder had no stones and its wall had an increased thickness. An abdominal CT scan (with and without contrast) showed severe hepatosplenomegaly, a hypodense area in the liver that might be a small hemangioma or cyst, considerable para-aortic adenopathy, and dilated small bowel loops with thickened walls. Her spleen was enlarged to a diameter of 13 cm and had homogenous echo. Her internal and external biliary tract liver were of normal diameter. There were some circular hypoechoic masses in our patient's portohepatic region, which indicated lymphadenopathy in this area. Her para-aortic region could not been observed because of the abdominal gas. Her intestinal loops were dilated in the pelvic region and were full of liquid.\nHer kidneys had normal secretions and appeared normal. No other abnormalities were seen. Her lungs were clear and of normal size, as shown on contrast chest X-ray. The chest X-ray also showed cardiomegaly. A CT scan of our patient's chest showed multiple lymph adenopathies in the paratracheal and subcarinal regions.\nOur patient's lung parenchymas were reported to be normal in a thorax CT scan with contrast. There were no effects of impressed masses, parenchymal nodules or abnormal infiltration. The vessels and bronchus seemed normal. Multiple lymph nodes were seen in the para-aorta, subcarina, lungs or esophagus.\nAnemia due to tumor involved all parts of the hematopoetic areas such as the liver, bone marrow and spleen, and also due to cardiac deficiency and endocarditis. Cardiac failure could occur after a bacterial endocarditis and the tumor development. There was also lymphadenopathy, pericardial effusion, fever, tremor, and edema.\nIn treating our patient, acute symptoms such as severe anemia, infection, electrolyte and biomedical imbalances and hypoglycemia were encountered. Once these had been treated, we addressed the Hodgkin's lymphoma.\nOur patient was given a high-protein and high-calorie diet, and treatment for tuberculosis was started. Gentamycin, penicillin, and vancomycin were prescribed because of the presenting endocarditis. After stabling the patient's condition, 14 sessions of chemotherapy were started. Chemotherapy included intravenous Adriamycin (doxorubicin) 25 mg/m2, Bleomycin 10 mg/m2, and vincristine 6 mg/m2, as well as 375 mg of dimethyl, triazeno, imidazole and carboxamide (DTIC) as infusion.\nAfter one year, no evidence of the disease were reported in a thorax CT scan with injection contrast or in abdominal and pelvic CT scans with oral and injection contrast. There was also no evidence of abnormal opacity in the lung parenchyma. The pathologic area was not seen either in the thorax bone structure or the adjacent soft tissue. There were no symptoms of either pleural fluid or pleural thickness. There was also no evidence of the anterior, medial of posterior mediastinal masses. The major vessels appeared normal. Small aortocaval and thorocaval lymph nodes were observed. A myeloma with a maximum diameter of 1 cm at the left kidney was detected. The size and density of our patient's kidneys were normal. The urine tract was not obstructed. The hilar areas were normal in both kidneys. The bronchus had normal calibers. The gall bladder and the internal and external liver biliary tracts were also normal. The spleen was of normal size and had systematic margins and homogenous density. The attenuation valve was also normal.\nAfter completing the treatment, our patient was discharged. Her parents were told that she should attend our clinic for follow up every three months. All the symptoms of the disease have now disappeared and the girl is living an ordinary life. She does not have symptoms of lymphadenopathy, splenomegaly or any other problems.", + "fulltext_subclaims": [ + "An 8-year-old Afghan girl presented with a two-month history of edema.", + "An 8-year-old Afghan girl presented with a two-month history of abdominal distension.", + "An 8-year-old Afghan girl presented with a two-month history of weakness.", + "An 8-year-old Afghan girl presented with a two-month history of pallor.", + "An 8-year-old Afghan girl presented with a two-month history of chills.", + "An 8-year-old Afghan girl presented with a two-month history of fever.", + "An 8-year-old Afghan girl presented with a two-month history of anorexia.", + "An 8-year-old Afghan girl presented with a two-month history of weight loss.", + "Physical examinations showed severe mucosal and conjunctival pallor.", + "Physical examinations showed periorbital and sacral edemas.", + "Physical examinations showed abdominal distension.", + "Tender mobile lymph nodes were found in the right neck (5 × 5 mm).", + "Tender mobile lymph nodes were found in the bilateral inguinal area (0.5 cm × 0.5 cm).", + "Tender mobile lymph nodes were found in the left axillary (0.7 cm × 0.7 cm).", + "Marked hepatosplenomegaly was observed.", + "Ascites with shifting dullness were observed.", + "Systolic murmurs (II/III) of the heart were apparent.", + "Hodgkin's lymphoma had metastasized to the myocardial tissue.", + "The tumor involved all the cardiac tissue and the septum.", + "Metastasis must have occurred via the blood vessels.", + "Other hematopoietic areas such as the liver, spleen, and bone marrow were also involved.", + "The symptoms of lymphadenopathy included enlargement of the lymph nodes.", + "There were symptoms of cardiac failure in the form of tachycardia.", + "There were symptoms of cardiac failure in the form of cardiomegaly.", + "There were symptoms of cardiac failure in the form of gallop rhythm.", + "There were symptoms of cardiac failure in the form of tachypnea.", + "There were symptoms of cardiac failure in the form of weak pulse.", + "There were symptoms of cardiac failure in the form of hypotension.", + "We used all diagnostic standards except positron emission tomography.", + "The patient had already been diagnosed with lymphoma and metastasis.", + "There were no signs of Hodgkin's lymphoma in the bone marrow.", + "Bone aspiration test results were negative.", + "Laboratory findings included severe anemia with moderate anisopoikilocytosis.", + "Hemoglobin level was 3.2 (normal range 260 to 400 mg/dl).", + "Erythrocyte sedimentation rate was 50 (normal range <15 mm/hr).", + "C-reactive protein was positive.", + "Polymerase chain reaction for tuberculosis was negative.", + "Blood culture was negative.", + "Urine culture was negative.", + "Hydatid antibody was negative.", + "Coombs Wright and 2 ME was negative.", + "Direct Coombs was negative.", + "Bone marrow culture was negative.", + "Blood smears for malaria and borrelia were negative.", + "G6PD level was normal.", + "Abdominal sonography showed an enlarged liver with heterogenic echo.", + "Marked hepatosplenomegaly (spans = 17 cm) was seen.", + "Two round hypoechoic areas in the hepatic portal space due to adenopathy were seen.", + "The biliary gall bladder had no stones.", + "The gall bladder wall had increased thickness.", + "An abdominal CT scan showed severe hepatosplenomegaly.", + "A hypodense area in the liver might be a small hemangioma or cyst.", + "Considerable para-aortic adenopathy was seen.", + "Dilated small bowel loops with thickened walls were seen.", + "The spleen was enlarged to a diameter of 13 cm.", + "The spleen had homogenous echo.", + "The internal and external biliary tract liver were of normal diameter.", + "Circular hypoechoic masses in the portohepatic region indicated lymphadenopathy.", + "The para-aortic region could not be observed because of abdominal gas.", + "The intestinal loops were dilated in the pelvic region and were full of liquid.", + "The kidneys had normal secretions.", + "The kidneys appeared normal.", + "The lungs were clear and of normal size.", + "The chest X-ray showed cardiomegaly.", + "A CT scan of the chest showed multiple lymph adenopathies in the paratracheal and subcarinal regions.", + "The lung parenchymas were reported to be normal.", + "There were no effects of impressed masses.", + "There were no parenchymal nodules.", + "There was no abnormal infiltration.", + "The vessels and bronchus seemed normal.", + "Multiple lymph nodes were seen in the para-aorta.", + "Multiple lymph nodes were seen in the subcarina.", + "Multiple lymph nodes were seen in the lungs or esophagus.", + "Anemia due to tumor involved all parts of the hematopoietic areas such as the liver, bone marrow, and spleen.", + "Anemia due to tumor also occurred due to cardiac deficiency and endocarditis.", + "Cardiac failure could occur after bacterial endocarditis.", + "Cardiac failure could occur after tumor development.", + "There was lymphadenopathy.", + "There was pericardial effusion.", + "There was fever.", + "There was tremor.", + "There was edema.", + "Acute symptoms such as severe anemia were encountered.", + "Acute symptoms such as infection were encountered.", + "Acute symptoms such as electrolyte imbalances were encountered.", + "Acute symptoms such as biomedical imbalances were encountered.", + "Acute symptoms such as hypoglycemia were encountered.", + "Once acute symptoms were treated, Hodgkin's lymphoma was addressed.", + "The patient was given a high-protein and high-calorie diet.", + "Treatment for tuberculosis was started.", + "Gentamycin was prescribed because of endocarditis.", + "Penicillin was prescribed because of endocarditis.", + "Vancomycin was prescribed because of endocarditis.", + "After stabilizing the patient's condition, 14 sessions of chemotherapy were started.", + "Chemotherapy included intravenous Adriamycin (doxorubicin) 25 mg/m2.", + "Chemotherapy included intravenous Bleomycin 10 mg/m2.", + "Chemotherapy included intravenous vincristine 6 mg/m2.", + "Chemotherapy included 375 mg of DTIC as infusion.", + "After one year, no evidence of the disease was reported in a thorax CT scan with injection contrast.", + "After one year, no evidence of the disease was reported in abdominal and pelvic CT scans with oral and injection contrast.", + "After one year, no evidence of abnormal opacity was reported in the lung parenchyma.", + "The pathologic area was not seen in the thorax bone structure.", + "The pathologic area was not seen in the adjacent soft tissue.", + "There were no symptoms of pleural fluid.", + "There were no symptoms of pleural thickness.", + "There was no evidence of anterior, medial, or posterior mediastinal masses.", + "The major vessels appeared normal.", + "Small aortocaval and thorocaval lymph nodes were observed.", + "A myeloma with a maximum diameter of 1 cm at the left kidney was detected.", + "The size and density of the kidneys were normal.", + "The urine tract was not obstructed.", + "The hilar areas were normal in both kidneys.", + "The bronchus had normal calibers.", + "The gall bladder and the internal and external liver biliary tracts were also normal.", + "The spleen was of normal size.", + "The spleen had systematic margins and homogenous density.", + "The attenuation valve was also normal.", + "After completing the treatment, the patient was discharged.", + "The parents were told that the patient should attend the clinic for follow up every three months.", + "All the symptoms of the disease have now disappeared.", + "The girl is living an ordinary life.", + "The girl does not have symptoms of lymphadenopathy.", + "The girl does not have symptoms of splenomegaly.", + "The girl does not have any other problems." + ], + "summary": "We report the case of an 8-year-old Afghan girl with Hodgkin's lymphoma. The disease presented with systemic signs and symptoms, including abdominal distension, weakness, pallor, chills, fever, generalized edema, hepatosplenomegaly and generalized lymphadenopathy, as well as signs of heart failure. Test results showed a rare form of heart metastasis.", + "summary_subclaims": [ + "The patient is an 8-year-old Afghan girl.", + "The patient has Hodgkin's lymphoma.", + "The disease presented with systemic signs and symptoms.", + "The patient had abdominal distension.", + "The patient had weakness.", + "The patient had pallor.", + "The patient had chills.", + "The patient had fever.", + "The patient had generalized edema.", + "The patient had hepatosplenomegaly.", + "The patient had generalized lymphadenopathy.", + "The patient had signs of heart failure.", + "Test results showed a rare form of heart metastasis." + ] + }, + { + "id": "multiclinsum_test_3082_en.txt", + "fulltext": "An 81-year-old male was admitted to the Huizhou Central People’s Hospital on September 18, 2022, with a principal complaint of fever and dyspnea. Three days before admission, the patient developed a fever with a maximum temperature of 39.5°C with no apparent cause. The fever was accompanied by dyspnea, chills, fatigue, muscle pain, and intermittent cough. The patient produced little sputum and did not complain of abdominal pain or diarrhea. The patient did not report marked improvement after self-medicating with oral cefuroxime and acetaminophen. One day prior, the patient visited the emergency department of our hospital. Chest computed tomography (CT) indicated a considerable consolidation in the left lung, patchy exudative lesions in the right lung, and a small amount of pleural effusion in the left lung. The patient received piperacillin-sulbactam (4.5 g IV q.8 h) antibiotic injections, but the fever persisted, and the patient was subsequently admitted. The patient had a 5-year history of type 2 diabetes mellitus and was not taking hypoglycemic medication regularly.\n\nPhysical examination revealed a body temperature of 39.1°C; pulse, 95 beats/min; respiratory rate, 30 breaths/min; and blood pressure, 132/70 mmHg. The patient was conscious but described feeling in poor spirits; there was no evidence of rash, subcutaneous bleeding, or superficial lymph node enlargement. Breathing was slightly rapid, with coarse breath sounds in bilateral lungs and wet rales in the left lower lung. No other major abnormalities were noted.\n\nLaboratory test results were as follows: blood gas analysis (FiO2 33%): pH, 7.505; pO2, 53 mmHg; pCO2, 27 mmHg; HCO3, 21.3 mmol/L; ferritin, >2000 µg/L (reference range: 13–150 µg/L); blood phosphorus, 1.52 mmol/L (reference range: 0.85–1.51 mmol/L); blood sodium, 145 mmol/L (reference range: 135–145 mmol/L); and urine erythrocytes, 530/µL (reference range: 0–17/µL).\n\nAfter admission, the patient was diagnosed with severe community-acquired pneumonia and administered meropenem injection (1.0 g IV q.8 h) and oseltamivir capsules (75 mg q. 12 h) as empirical antibiotic/antiviral treatment, hepatoprotective medication, and transnasal high-flow oxygen therapy. The patient’s dyspnea was aggravated on the night of admission, with the oxygenation index falling to 62.5, leading to the initiation of emergency tracheal intubation and invasive mechanical ventilation. Given that the patient had a severe infection of unknown etiology, 10 mL of bronchoalveolar lavage fluid was collected via fiberoptic bronchoscopy on day 2 after admission for metagenomic next-generation sequencing (mNGS). During this period, antinuclear antibody panel, serum 1,3-β-D-glucan assay (G test), galactomannan (GM) assay, SARS-CoV-2 nucleic acid test, Legionella DNA test, and tests for IgM antibodies to respiratory pathogens (including L. pneumophila, Mycoplasma pneumoniae, Rickettsia, Chlamydia pneumoniae, adenovirus, respiratory syncytial virus, influenza A virus, influenza B virus, and parainfluenza virus) were all negative. Additionally, multiple sputum and blood cultures were negative. On day 4 after admission, the patient’s temperature remained above 38.5°C, the dyspnea did not improve, cough and sputum increased, inflammatory indicators were higher than before, and severe liver and renal insufficiency was observed. Chest CT re-examination indicated bilateral increases in lung lesions. On day 4 after admission, mNGS results indicated the presence of L. pneumophila (76 sequences, coverage 32%) and Candida albicans (115 sequences, coverage 43%). According to the clinical manifestations and results of mNGS, severe L. pneumophila pneumonia was suggested. Given the severe hepatic and renal dysfunction, the antibiotic regimen was changed to omadacycline injection (first dose: 200 mg IV q.d., second dose: 100 mg IV q.d). Five days later, the dyspnea resolved completely, re-examination of inflammation and organ function indicators showed dramatic improvement, and intravenous omadacycline was continued. On day 14, the patient was weaned from tracheal intubation, and transnasal high-flow oxygen therapy was administered. On day 22, all inflammation and organ function indicators had generally returned to normal, and chest CT indicated that the bilateral lung lesions were markedly resolved. Omadacycline was discontinued, and the patient was discharged the following day. At the 2-month follow-up, the patient’s general condition was satisfactory, with only occasional cough and no dyspnea. Chest CT indicated the lung lesions were almost entirely resolved, with only a few fibrotic streaks remaining.", + "fulltext_subclaims": [ + "An 81-year-old male was admitted to the Huizhou Central People’s Hospital on September 18, 2022.", + "The principal complaint was fever and dyspnea.", + "Three days before admission, the patient developed a fever with a maximum temperature of 39.5°C.", + "The fever was accompanied by dyspnea, chills, fatigue, muscle pain, and intermittent cough.", + "The patient produced little sputum.", + "The patient did not complain of abdominal pain or diarrhea.", + "The patient did not report marked improvement after self-medicating with oral cefuroxime and acetaminophen.", + "Chest computed tomography (CT) indicated a considerable consolidation in the left lung.", + "Chest CT showed patchy exudative lesions in the right lung.", + "Chest CT showed a small amount of pleural effusion in the left lung.", + "The patient received piperacillin-sulbactam (4.5 g IV q.8 h) antibiotic injections.", + "The fever persisted after piperacillin-sulbactam.", + "The patient had a 5-year history of type 2 diabetes mellitus.", + "The patient was not taking hypoglycemic medication regularly.", + "Physical examination revealed a body temperature of 39.1°C.", + "Physical examination showed a respiratory rate of 30 breaths/min.", + "Breathing was slightly rapid.", + "Coarse breath sounds were heard in bilateral lungs.", + "Wet rales were heard in the left lower lung.", + "Blood gas analysis (FiO2 33%) showed pH 7.505.", + "Blood gas analysis showed pO2 53 mmHg.", + "Blood gas analysis showed pCO2 27 mmHg.", + "Blood gas analysis showed HCO3 21.3 mmol/L.", + "Ferritin was >2000 µg/L.", + "Blood phosphorus was 1.52 mmol/L.", + "Blood sodium was 145 mmol/L.", + "Urine erythrocytes were 530/µL.", + "The patient was diagnosed with severe community-acquired pneumonia.", + "The patient received meropenem injection (1.0 g IV q.8 h).", + "The patient received oseltamivir capsules (75 mg q. 12 h).", + "The patient received transnasal high-flow oxygen therapy.", + "The patient’s dyspnea was aggravated on the night of admission.", + "The oxygenation index fell to 62.5.", + "Emergency tracheal intubation and invasive mechanical ventilation were initiated.", + "mNGS results indicated the presence of L. pneumophila (76 sequences, coverage 32%).", + "mNGS results indicated the presence of Candida albicans (115 sequences, coverage 43%).", + "Severe L. pneumophila pneumonia was suggested.", + "The antibiotic regimen was changed to omadacycline injection.", + "The first dose of omadacycline was 200 mg IV q.d.", + "The second dose of omadacycline was 100 mg IV q.d.", + "Five days after starting omadacycline, the dyspnea resolved completely.", + "Inflammation and organ function indicators showed dramatic improvement.", + "On day 14, the patient was weaned from tracheal intubation.", + "On day 22, all inflammation and organ function indicators had generally returned to normal.", + "Chest CT indicated that the bilateral lung lesions were markedly resolved.", + "Omadacycline was discontinued.", + "The patient was discharged the following day.", + "At the 2-month follow-up, the patient’s general condition was satisfactory.", + "Chest CT indicated the lung lesions were almost entirely resolved." + ], + "summary": "Here, we report a case of severe pneumonia caused by Legionella infection. The patient was empirically treated with antibiotics, after admission but had a poor clinical outcome with severe hepatic and renal insufficiency. After Legionella infection was confirmed by metagenomic next-generation sequencing, the patient was switched to omadacycline antibiotic therapy and eventually discharged after recovery.", + "summary_subclaims": [ + "This is a case of severe pneumonia caused by Legionella infection.", + "The patient was empirically treated with antibiotics after admission.", + "The patient had a poor clinical outcome with severe hepatic and renal insufficiency.", + "Legionella infection was confirmed by metagenomic next-generation sequencing.", + "The patient was switched to omadacycline antibiotic therapy.", + "The patient was eventually discharged after recovery." + ] + }, + { + "id": "multiclinsum_test_1044_en.txt", + "fulltext": "The patient was a 37-year-old male from a non-consanguineous Chinese family. Since the age of 35, he had experienced progressive weakness of his hands and a reduction of grip strength, especially in his right hand. Six months later, muscle atrophy and muscle fibrillation were noticed in his hands, and he was unable to hold things or to write. One year later, he experienced weakness in his lower extremities with no sensory disturbance. He currently experiences difficulty in climbing the stairs and standing up from a squatting position, is unable to lift his foot upward, and trips over easily. Physical examination revealed that the cranial nerves were normal, and that orolingual fasciculations and atrophy were absent. The neck flexion strength was 5 (MRC muscle scale, grades 0–5). The muscle strength of both sides of the body was as follows: triceps and biceps 3/3, forearm flexors 2/2, intrinsic hand muscles 1/1, iliopsoas muscles 4/4, quadriceps muscles 3/3, tibialis anterior and gastrocnemius muscles 2/2. Deep tendon reflexes were absent. There was no sensory abnormality or coordination difficulty of any of the limbs. Atrophy was seen in most of the muscles, especially the interosseous muscles of the hands, bilateral gastrocnemius and anterior tibial muscles . Muscle fibrillation was observed in the biceps and quadriceps muscles.\nThe patient’s serum level of creatine kinase was 668 U/L (normal range, 50–310 U/L). Extractable nuclear antigens were negative, and serum sex hormone levels were normal. Peripheral neuropathy antibodies such as GM1-antibody and GQ1b-antibody were also negative, and there was no albuminocytological dissociation of his cerebrospinal fluid. The nerve conduction velocity revealed severe reduction in compound muscle action potential (CMAP) amplitudes and motor conduction velocities in bilateral median nerves, ulnar nerves, and radial nerves, while the sensory conduction was normal (Additional file A and B). Right ulnar nerve F-waves were absent. Chronic denervation/reinnervation (e.g., motor unit action potentials of increased amplitude and duration, with reduced inference patterns) was observed in three regions on the electromyogram (EMG), including the bilateral extremities and sternocleidomastoid muscles (Additional file C, D and E). And spontaneous activity (positive sharp waves) was recorded from these muscles. Echocardiography and electrocardiogram evaluations did not detect any cardiac abnormalities. Lower limb muscle MRI showed marked involvement of the gastrocnemius muscle at the calf level. There was a strongly increased signal intensity in turbo inversion recovery magnitude (TIRM) sequences, indicating muscular edema. A mild increase in the signal intensity of soleus and tibialis anterior muscles was observed in the T2 sequence, indicating fat replacement . At the proximal leg level, slight fatty degeneration was detected in the posterior compartment, such as the semimembranosus and semitendinosus muscles .\nAfter providing written consent, a skeletal muscle biopsy was taken from the patient’s gastrocnemius muscle, precooled with isopentane, and frozen in liquid nitrogen. Frozen sections of 8 μm were then prepared and examined by light microscopy. A marked variation in fiber size was observed, with many angular atrophic fibers. Some fibers also showed structural changes with abnormal material deposits after staining with hematoxylin–eosin . On Gomori trichrome-stained sections, these abnormal deposits appeared as purple inclusions. They varied in size, shape, and thickness, and were either single or multiple . In the NADH-tetrazolium reductase reaction, oxidative activity was reduced in fibrous areas occupied by the inclusions, showing core-like lesions . Neurogenic changes, such as the grouping of angular atrophic fibers, were also present. Immunohistochemical analysis showed prominent FLNC immunoreactive deposits accumulating at subsarcolemmal and sarcoplasmic levels . Electron microscopy of the available transverse sections showed an inordinate myofibrillar structure and dissolved myofilaments. Subsarcolemmal accumulations of lipofuscin were also present .\nNext-generation sequencing identified a heterozygous missense mutation (c.7123G > A, p.V2375I) in the Ig-like domain 21 of FLNC . Confirmation of the variant was undertaken by Sanger sequencing using an ABI 3730XL DNA Sequencer (Applied Biosystems, Thermo Fisher Scientific, USA). The mutation was absent in the DNA of 100 healthy unrelated controls, and the allele frequency in the Asian population is zero according to the Exome Aggregation Consortium . The p.V2375I missense mutation affects valine at position 2375, which is highly conserved from mice to humans . To exclude other hereditary diseases similar to LMN disease, we also tested for mutations in the genes disrupted in SMAs and the androgen receptor gene, but none were found. Since the patient had no immediate family members and loses contact with other family members, further co-segregation analyses among the family cannot be conducted.", + "fulltext_subclaims": [ + "The patient was a 37-year-old male from a non-consanguineous Chinese family.", + "Since the age of 35, he had experienced progressive weakness of his hands.", + "He had a reduction of grip strength, especially in his right hand.", + "Six months later, muscle atrophy and muscle fibrillation were noticed in his hands.", + "He was unable to hold things or to write.", + "One year later, he experienced weakness in his lower extremities.", + "He currently experiences difficulty in climbing the stairs and standing up from a squatting position.", + "He is unable to lift his foot upward.", + "He trips over easily.", + "Physical examination revealed that the cranial nerves were normal.", + "Orolingual fasciculations and atrophy were absent.", + "The neck flexion strength was 5 (MRC muscle scale, grades 0–5).", + "The muscle strength of both sides of the body was as follows: triceps and biceps 3/3, forearm flexors 2/2, intrinsic hand muscles 1/1, iliopsoas muscles 4/4, quadriceps muscles 3/3, tibialis anterior and gastrocnemius muscles 2/2.", + "Deep tendon reflexes were absent.", + "There was no sensory abnormality or coordination difficulty of any of the limbs.", + "Atrophy was seen in most of the muscles, especially the interosseous muscles of the hands, bilateral gastrocnemius and anterior tibial muscles.", + "Muscle fibrillation was observed in the biceps and quadriceps muscles.", + "The patient’s serum level of creatine kinase was 668 U/L.", + "Extractable nuclear antigens were negative.", + "Serum sex hormone levels were normal.", + "Peripheral neuropathy antibodies such as GM1-antibody and GQ1b-antibody were also negative.", + "There was no albuminocytological dissociation of his cerebrospinal fluid.", + "The nerve conduction velocity revealed severe reduction in compound muscle action potential (CMAP) amplitudes and motor conduction velocities in bilateral median nerves, ulnar nerves, and radial nerves.", + "The sensory conduction was normal.", + "Right ulnar nerve F-waves were absent.", + "Chronic denervation/reinnervation was observed in three regions on the electromyogram (EMG), including the bilateral extremities and sternocleidomastoid muscles.", + "Spontaneous activity (positive sharp waves) was recorded from these muscles.", + "Echocardiography and electrocardiogram evaluations did not detect any cardiac abnormalities.", + "Lower limb muscle MRI showed marked involvement of the gastrocnemius muscle at the calf level.", + "There was a strongly increased signal intensity in turbo inversion recovery magnitude (TIRM) sequences, indicating muscular edema.", + "A mild increase in the signal intensity of soleus and tibialis anterior muscles was observed in the T2 sequence, indicating fat replacement.", + "At the proximal leg level, slight fatty degeneration was detected in the posterior compartment, such as the semimembranosus and semitendinosus muscles.", + "A skeletal muscle biopsy was taken from the patient’s gastrocnemius muscle.", + "Frozen sections of 8 μm were then prepared and examined by light microscopy.", + "A marked variation in fiber size was observed, with many angular atrophic fibers.", + "Some fibers also showed structural changes with abnormal material deposits after staining with hematoxylin–eosin.", + "On Gomori trichrome-stained sections, these abnormal deposits appeared as purple inclusions.", + "They varied in size, shape, and thickness, and were either single or multiple.", + "In the NADH-tetrazolium reductase reaction, oxidative activity was reduced in fibrous areas occupied by the inclusions, showing core-like lesions.", + "Neurogenic changes, such as the grouping of angular atrophic fibers, were also present.", + "Immunohistochemical analysis showed prominent FLNC immunoreactive deposits accumulating at subsarcolemmal and sarcoplasmic levels.", + "Electron microscopy of the available transverse sections showed an inordinate myofibrillar structure and dissolved myofilaments.", + "Subsarcolemmal accumulations of lipofuscin were also present.", + "Next-generation sequencing identified a heterozygous missense mutation (c.7123G > A, p.V2375I) in the Ig-like domain 21 of FLNC.", + "Confirmation of the variant was undertaken by Sanger sequencing using an ABI 3730XL DNA Sequencer.", + "The mutation was absent in the DNA of 100 healthy unrelated controls.", + "The allele frequency in the Asian population is zero according to the Exome Aggregation Consortium.", + "The p.V2375I missense mutation affects valine at position 2375, which is highly conserved from mice to humans.", + "We also tested for mutations in the genes disrupted in SMAs and the androgen receptor gene, but none were found.", + "Since the patient had no immediate family members and loses contact with other family members, further co-segregation analyses among the family cannot be conducted." + ], + "summary": "The patient was a 37-year-old male who first experienced weakness in the distal muscles of his hand, which eventually spread to the lower limbs and proximal muscles. Serum creatine kinase levels were moderately elevated. Obvious neuropathic changes in the electromyographic exam and edema changes in lower distal limb magnetic resonance imaging were observed. Histopathological examination revealed the presence of abnormal protein aggregates and angular atrophy in some muscle fibers. Ultrastructural analysis showed inordinate myofibrillar structures and dissolved myofilaments. DNA sequencing analysis detected a heterozygous missense mutation (c.7123G > A, p.V2375I) in the immunoglobulin (Ig)-like domain 21 of FLNC.", + "summary_subclaims": [ + "The patient was a 37-year-old male.", + "The patient first experienced weakness in the distal muscles of his hand.", + "The weakness eventually spread to the lower limbs and proximal muscles.", + "Serum creatine kinase levels were moderately elevated.", + "Obvious neuropathic changes were observed in the electromyographic exam.", + "Edema changes were observed in lower distal limb magnetic resonance imaging.", + "Histopathological examination revealed the presence of abnormal protein aggregates.", + "Histopathological examination revealed angular atrophy in some muscle fibers.", + "Ultrastructural analysis showed inordinate myofibrillar structures.", + "Ultrastructural analysis showed dissolved myofilaments.", + "DNA sequencing analysis detected a heterozygous missense mutation (c.7123G > A, p.V2375I) in the immunoglobulin (Ig)-like domain 21 of FLNC." + ] + }, + { + "id": "multiclinsum_test_3329_en.txt", + "fulltext": "A 57-year-old Caucasian man was admitted to the Emergency Department due to anxiety, confusion, tachycardia, and dyspnea. The patient did not report any significant past medical history. The patient did not take any medication, did not consume alcohol, and did not smoke. Admission vital signs were noted: regular radial pulse with an average heart rate of 110 beats per minute, arterial pressure of 180/90 mmHg and peripheral oxygen blood saturation (SpO 2) of 90% in ambient air and spontaneous breathing with an average respiratory rate of 25 breaths per minute. The axillary temperature was normal. Cardiac examination revealed a regular rate and rhythm with normal heart sounds and a holosystolic murmur at the apex. Chest examination noted symmetrical thoracic activity, normal expansion, and bilateral basal end-inspiratory crackles. Abdominal examination was normal; no swelling of the feet or legs was detected but the extremities were cold. The patient was alert, answered simple questions accurately and was able to execute simple tasks; the pupils were equal, round and normally reactive to light; the neurological examination was normal. The patient lived in the countryside and used a pellet stove to heat his bedroom without any aeration system. An arterial blood gas analysis showed respiratory acidosis with hyperlactatemia, increased anion gap, and a concentration of COHb above 15%. CXR detected pulmonary edema. The ECG showed sinus tachycardia with ST-segment elevation in the precordial V1-V6 leads.\n\nThe patient rapidly decompensated with the onset of hypotension (systolic BP < 90 mmHg), worsening hypoxemia, and respiratory acidosis.\n\nHe was admitted to the Intensive Care Unit (ICU). Acute Heart Failure (AHF) with cardiogenic shock and respiratory failure was suspected. A transthoracic echocardiogram (TTE) was performed and demonstrated globally reduced left ventricular contractile function with ejection fraction of 20-25% and a severe mitral regurgitation; the pericardium was normal. The patient was treated with ventilatory and circulatory support. He underwent an orotracheal intubation under sedation with subsequent lung protective mechanical ventilation and inotropic support. The patient responded quickly, and peripheral perfusion was restored. As the patient was confused and had cardiovascular failure and acidosis, hyperbaric oxygen therapy was started and maintained until COHb concentration was reduced to normal values (<3%)25,50 . Blood cell count, electrolytes, renal, liver, and thyroid function were all within the normal range.\nCreatine kinase (CK), creatine kinase-muscle/brain (CK-MB), troponin and lactate dehydrogenase (LDH) were higher than the normal value. The amino-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) was slightly elevated. The ECG showed a pattern indicating an Acute Coronary Syndrome (ACS). Given the ECG findings and the increased concentration of myocardial necrosis markers, a coronary angiography was performed but it did not detect any stenosis or other abnormalities of the coronary arteries. It was supposed that ECG finding was related to coronary vasospasm related to CO intoxication. After 12 hours of mechanical support, lung function improved, and no further evidence of cardiopulmonary failure was observed. The subsequent arterial blood gas analysis was normal, and the radiogram of the chest showed no further evidence of pulmonary edema. The cardiac necrosis markers decreased to normal levels. The TTE was repeated and detected an improved EF to 50-60% with no global dysfunction; mitral regurgitation was no longer documented. The patient was extubated and discharged to the Internal Medicine (IM) ward for monitoring and care. He remained hemodynamically stable for the following two days and discharged. Three days later, he was re-admitted to the Emergency Room (ER) with the same cardiovascular condition. He had the same TTE pattern of the previous admission with decreased ejection fraction (EF) and global left ventricular dysfunction. The measured COHb level was higher than 20%. He died from acute cardiac failure and cardiac arrest with pulseless electric activity (PEA) despite prompt treatment and resuscitative measures.", + "fulltext_subclaims": [ + "A 57-year-old Caucasian man was admitted to the Emergency Department due to anxiety, confusion, tachycardia, and dyspnea.", + "The patient did not report any significant past medical history.", + "The patient did not take any medication, did not consume alcohol, and did not smoke.", + "Admission vital signs were noted: regular radial pulse with an average heart rate of 110 beats per minute.", + "Arterial pressure was 180/90 mmHg.", + "Peripheral oxygen blood saturation (SpO2) was 90% in ambient air.", + "The axillary temperature was normal.", + "Cardiac examination revealed a regular rate and rhythm with normal heart sounds and a holosystolic murmur at the apex.", + "Chest examination noted symmetrical thoracic activity, normal expansion, and bilateral basal end-inspiratory crackles.", + "The patient lived in the countryside and used a pellet stove to heat his bedroom without any aeration system.", + "An arterial blood gas analysis showed respiratory acidosis with hyperlactatemia, increased anion gap, and a concentration of COHb above 15%.", + "CXR detected pulmonary edema.", + "The ECG showed sinus tachycardia with ST-segment elevation in the precordial V1-V6 leads.", + "The patient rapidly decompensated with the onset of hypotension (systolic BP < 90 mmHg), worsening hypoxemia, and respiratory acidosis.", + "He was admitted to the Intensive Care Unit (ICU).", + "Acute Heart Failure (AHF) with cardiogenic shock and respiratory failure was suspected.", + "A transthoracic echocardiogram (TTE) was performed and demonstrated globally reduced left ventricular contractile function with ejection fraction of 20-25% and a severe mitral regurgitation.", + "The patient was treated with ventilatory and circulatory support.", + "He underwent an orotracheal intubation under sedation with subsequent lung protective mechanical ventilation and inotropic support.", + "The patient responded quickly, and peripheral perfusion was restored.", + "As the patient was confused and had cardiovascular failure and acidosis, hyperbaric oxygen therapy was started and maintained until COHb concentration was reduced to normal values (<3%).", + "Creatine kinase (CK), creatine kinase-muscle/brain (CK-MB), troponin and lactate dehydrogenase (LDH) were higher than the normal value.", + "The amino-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) was slightly elevated.", + "The ECG showed a pattern indicating an Acute Coronary Syndrome (ACS).", + "Given the ECG findings and the increased concentration of myocardial necrosis markers, a coronary angiography was performed but it did not detect any stenosis or other abnormalities of the coronary arteries.", + "It was supposed that ECG finding was related to coronary vasospasm related to CO intoxication.", + "After 12 hours of mechanical support, lung function improved, and no further evidence of cardiopulmonary failure was observed.", + "The subsequent arterial blood gas analysis was normal.", + "The radiogram of the chest showed no further evidence of pulmonary edema.", + "The cardiac necrosis markers decreased to normal levels.", + "The TTE was repeated and detected an improved EF to 50-60% with no global dysfunction; mitral regurgitation was no longer documented.", + "The patient was extubated and discharged to the Internal Medicine (IM) ward for monitoring and care.", + "He remained hemodynamically stable for the following two days and discharged.", + "Three days later, he was re-admitted to the Emergency Room (ER) with the same cardiovascular condition.", + "He had the same TTE pattern of the previous admission with decreased ejection fraction (EF) and global left ventricular dysfunction.", + "The measured COHb level was higher than 20%.", + "He died from acute cardiac failure and cardiac arrest with pulseless electric activity (PEA) despite prompt treatment and resuscitative measures." + ], + "summary": "A 57-year-old man was admitted to the emergency department for acute carbon monoxide poisoning that led to respiratory and cardiac failure. The electrocardiogram showed ST elevation in precordial leads, but the coronary angiography was normal. The patient was successfully treated and discharged. Three days later he was readmitted for similar symptoms and subsequently died. We hypothesize that the ECG findings were related to transient coronary vasospasm due to CO poisoning and that acute respiratory and cardiac failure related to carbon monoxide toxicity caused death.", + "summary_subclaims": [ + "The patient was a 57-year-old man.", + "The patient was admitted to the emergency department for acute carbon monoxide poisoning.", + "The carbon monoxide poisoning led to respiratory and cardiac failure.", + "The electrocardiogram showed ST elevation in precordial leads.", + "The coronary angiography was normal.", + "The patient was successfully treated and discharged.", + "Three days later he was readmitted for similar symptoms.", + "The patient subsequently died.", + "We hypothesize that the ECG findings were related to transient coronary vasospasm due to CO poisoning.", + "We hypothesize that acute respiratory and cardiac failure related to carbon monoxide toxicity caused death." + ] + }, + { + "id": "multiclinsum_test_3023_en.txt", + "fulltext": "A 66-year-old man, without known systemic diseases, was referred to our department with a progressive decrease in visual acuity of his right eye (RE).\n\nHe had been assisted at our department more than 10 years before due to exudative bilateral maculopathy of unknown etiology. At that time, exuberant atrophic macular abnormalities had been recorded in both eyes, more pronounced in the LE. He had been submitted to full dose photodynamic therapy with verteporfin (PDT) and several anti-VEGF intravitreal injections. He underwent cataract surgery with intraocular lens implant. In the last registered visit, he presented a corrected distance visual acuity (CDVA) of 20/32 on his RE and counting fingers on his LE.\n\nThe patient was lost to follow-up at our department for 10 years and he returned in December 2020 complaining of RE vision loss. The CDVA was 20/63 on the RE and counting fingers on the LE. On slit-lamp examination, no anterior chamber reaction was observed but a vitreous haze was present on the RE. Fundoscopy revealed bilateral large, yellowish lesions located in the macula, associated with significant atrophy, particularly in the LE. No changes were observed in peripheral retina.\n\nOptical coherence tomography (OCT) showed a flat retinal pigmented epithelium (RPE) detachment with hyper-reflective material under RPE, damage of external retinal layers, including external limiting membrane, ellipsoid zone and RPE, and cystoid macular edema on the RE. The LE showed a large area of macular atrophy, with subretinal fibrosis; both eyes exhibited an anomalous OCT pattern of the inner choroid with extensive loss of choriocapillaris. Fundus autofluorescence (FAF) showed central hypoautofluorescence secondary to RPE and photoreceptors loss.\n\nThe RE FA showed an early irregular pattern with significant late hyperfluorescence due to staining. On the LE, a large early hypofluorescent lesion involving all macular areas and extending to the temporal optic disc border, with well-defined edges and late internal hyperfluorescent areas, was defined. In the indocyanine green angiography (ICGA), an heterogenous pattern with anomalous dilated choroidal vessels could be observed.\n\nThe OCT angiography (OCTA) of the RE demonstrated an anomalous vascular network, suggestive of choroidal neovascularization.\n\nSystemic work-up revealed a positive TPHA test and a negative VDRL. The patient confirmed a known past history of syphilis of more than 30 years eventually treated with oral antibiotics, when living in a sub-Saharan African country. Since then, the patient did not develop any other symptoms or signs suggestive of syphilis. No other significant changes were found on the systemic work-up, including evidence of other infectious or immune diseases.\n\nWith collaboration of the Infectious Diseases department, the patient was admitted in the hospital and started systemic treatment with intravenous Penicillin G for 14 days as well as intravitreal ranibizumab injections on the RE in a PRN regimen.\n\nAfter systemic and intravitreal treatment, the patient experienced visual acuity improvement to 20/25, without metamorphopsia. There was a regression of the RPE detachment and cystoid macular edema, since the first month after systemic treatment.\n\nA regular follow-up is maintained in order to evaluate the need for repeated intravitreal injections.", + "fulltext_subclaims": [ + "The patient is a 66-year-old man.", + "The patient was referred with a progressive decrease in visual acuity of his right eye.", + "The patient had been assisted at the department more than 10 years before.", + "At that time, exudative bilateral maculopathy of unknown etiology was recorded.", + "Exuberant atrophic macular abnormalities had been recorded in both eyes.", + "The atrophic macular abnormalities were more pronounced in the left eye.", + "The patient had been submitted to full dose photodynamic therapy with verteporfin.", + "The patient had been submitted to several anti-VEGF intravitreal injections.", + "The patient underwent cataract surgery with intraocular lens implant.", + "In the last registered visit, the corrected distance visual acuity of the right eye was 20/32.", + "In the last registered visit, the corrected distance visual acuity of the left eye was counting fingers.", + "The patient was lost to follow-up at the department for 10 years.", + "The patient returned in December 2020 complaining of right eye vision loss.", + "The corrected distance visual acuity of the right eye was 20/63.", + "The corrected distance visual acuity of the left eye was counting fingers.", + "Fundoscopy revealed bilateral large, yellowish lesions located in the macula.", + "The lesions were associated with significant atrophy, particularly in the left eye.", + "Optical coherence tomography showed a flat retinal pigmented epithelium detachment with hyper-reflective material under RPE in the right eye.", + "Optical coherence tomography showed damage of external retinal layers in the right eye.", + "The right eye showed cystoid macular edema.", + "The left eye showed a large area of macular atrophy with subretinal fibrosis.", + "Both eyes exhibited an anomalous OCT pattern of the inner choroid with extensive loss of choriocapillaris.", + "Fundus autofluorescence showed central hypoautofluorescence secondary to RPE and photoreceptors loss.", + "The right eye FA showed an early irregular pattern with significant late hyperfluorescence due to staining.", + "The left eye FA showed a large early hypofluorescent lesion involving all macular areas.", + "The left eye FA lesion extended to the temporal optic disc border.", + "The left eye FA lesion had well-defined edges and late internal hyperfluorescent areas.", + "The ICGA showed an heterogeneous pattern with anomalous dilated choroidal vessels.", + "The OCT angiography of the right eye demonstrated an anomalous vascular network, suggestive of choroidal neovascularization.", + "Systemic work-up revealed a positive TPHA test.", + "Systemic work-up revealed a negative VDRL.", + "The patient confirmed a known past history of syphilis of more than 30 years.", + "The patient had been treated with oral antibiotics for syphilis.", + "The patient had lived in a sub-Saharan African country when treated for syphilis.", + "The patient did not develop any other symptoms or signs suggestive of syphilis since treatment.", + "The patient was admitted to the hospital.", + "The patient was started on systemic treatment with intravenous Penicillin G for 14 days.", + "The patient received intravitreal ranibizumab injections on the right eye in a PRN regimen.", + "After treatment, the patient experienced visual acuity improvement to 20/25.", + "There was a regression of the RPE detachment and cystoid macular edema in the first month after systemic treatment.", + "A regular follow-up is maintained to evaluate the need for repeated intravitreal injections." + ], + "summary": "A healthy 66-year-old man complained of decreased visual acuity in the right eye (RE). He had a past history of bilateral exudative maculopathy of unknown etiology, lasting for more than 10 years and leading to severe and irreversible vision loss on the left eye. The corrected distance visual acuity (CDVA) was 20/63 on the RE and <20/400 on the left eye (LE). On slit-lamp, no anterior chamber reaction was observed, a vitreous haze was present on the RE as well as large, bilateral yellowish lesions in the macula, with exuberant macular atrophy, particularly on the LE. These well-defined lesions were confined to the posterior pole. The spectral domain optical coherence tomography (SD-OCT) showed a flat retinal pigmented epithelium (RPE) detachment with hyperreflective material beneath the RPE and cystoid macular edema on the RE and an exuberant macular atrophy on the LE, with both eyes showing anomalous enlargement of choroidal vessels. The fluorescein angiography showed general hypofluorescence and indocyanine green angiography revealed a heterogeneous pattern. The OCT angiography (OCTA) of the RE demonstrated an anomalous vascular network related to the presence of choroidal neovascularization (CNV). An etiological study was performed and a positive treponemal test (TPHA) was found. The patient experienced visual acuity improvement to 20/25 after systemic treatment with Penicillin and anti-VEGF injections.", + "summary_subclaims": [ + "The patient is a 66-year-old man.", + "The patient complained of decreased visual acuity in the right eye.", + "The patient had a past history of bilateral exudative maculopathy of unknown etiology.", + "The exudative maculopathy lasted for more than 10 years.", + "The exudative maculopathy led to severe and irreversible vision loss on the left eye.", + "The corrected distance visual acuity was 20/63 on the right eye.", + "The corrected distance visual acuity was <20/400 on the left eye.", + "No anterior chamber reaction was observed on slit-lamp examination.", + "A vitreous haze was present on the right eye.", + "Large, bilateral yellowish lesions were present in the macula.", + "Exuberant macular atrophy was present, particularly on the left eye.", + "The lesions were confined to the posterior pole.", + "The SD-OCT showed a flat retinal pigmented epithelium detachment with hyperreflective material beneath the RPE on the right eye.", + "The SD-OCT showed cystoid macular edema on the right eye.", + "The SD-OCT showed exuberant macular atrophy on the left eye.", + "Both eyes showed anomalous enlargement of choroidal vessels.", + "The fluorescein angiography showed general hypofluorescence.", + "The indocyanine green angiography revealed a heterogeneous pattern.", + "The OCTA of the right eye demonstrated an anomalous vascular network related to the presence of choroidal neovascularization.", + "An etiological study was performed.", + "A positive treponemal test (TPHA) was found.", + "The patient experienced visual acuity improvement to 20/25 after systemic treatment with Penicillin and anti-VEGF injections." + ] + }, + { + "id": "multiclinsum_test_2517_en.txt", + "fulltext": "A 68-year-old Caucasian man with glaucoma who was receiving chronic therapy was referred to our institution with a diagnosis of post-operative endophthalmitis in the left eye. The patient had inflammation in the left eye that had started a few days earlier and was associated with impaired vision. Two weeks before presentation he had undergone cataract surgery combined with a glaucoma shunt implant at another eye clinic.\nUpon presentation, he had a corrected distance visual acuity (CDVA) of 20/80 in the right eye, a cortical and nuclear cataract and filtering bleb that had developed after previous glaucoma surgery. Upon presentation, he had a corrected distance visual acuity (CDVA) of 20/80 in the right eye, a filtering bleb and a cortical and nuclear cataract developed after the previous glaucoma surgery performed two years earlier.\nA glaucomatous optic disc excavation was present and the visual field was significantly narrowed in the inferior nasal area. He was receiving therapy with bimatoprost eyedrops in this eye.\nHis CDVA in the left eye was 1/200, and he showed marked conjunctival injection, corneal edema, inflammatory aqueous cells (Tyndall 3+) and fibrin on the front face of the intra-ocular lens (IOL). The glaucoma shunt implant (EX-PRESS® Glaucoma Filtration Device; Alcon Laboratories, Fort Worth, TX, USA) was in site with a non-inflamed filtering bleb. There was dense vitritis, and it was impossible to visualize the retina and the optic disc. A 25-gauge pars plana vitrectomy (PPV) was performed using a CONSTELLATION® vitrectomy system (Alcon Surgical, Tokyo, Japan), and infusion fluid (BSS PLUS®; Alcon Surgical) was devoid of any antibiotics. At a site 4.0mm from and parallel to the limbus, three trocars were inserted at a 30° angle (one in the inferonasal area for the infusion), creating tunnel sclerotomies. Initially, a vitreous sample (with the infusion channel closed) was collected using the vitrectome, then the remaining vitrectomy with hyaloid removal was completed. The vitreous cavity was filled with silicone oil, and ceftazidime and vancomycin were injected intravitreally. All the sclerotomies were sutured because of the risk of leakage.\nDuring surgery, the retina appeared to be covered by an abundant fibrinous exudation. After surgery, the patient’s CDVA was 1/30, and therapy with topical vancomycin (50mg/ml) and ceftazidime (50mg/ml) eyedrops six times per day was started. The IOL and the glaucoma valve were left in place because the patient strongly expressed this desire, given the low visual acuity of the other eye. Cultures taken from the aqueous and vitreous were negative, and his early post-operative course was uneventful and without signs of significant inflammation, except for a thin layer of fibrin on the front face of the IOL. He was discharged some five days after surgery, and he continued the therapy at home and returned for scheduled checks. During these checks, his CDVA was 1/20 and there were no signs of inflammation in the anterior chamber; however, the retina could not be easily evaluated, owing to fibrin plaque on the surface of the IOL.Forty-five days after this surgery, he experienced acute, increasing pain in the left eye with severe inflammation, corneal edema, anterior chamber inflammation (Tyndall 4+) and hypopyon occupying three-fourths of the anterior chamber . He underwent a new anterior chamber washout with aqueous sample and a vitrectomy with silicone oil tamponade.\nTwo days after his second surgery, an increase of intra-ocular pressure was observed (treated with topical and systemic therapy) associated with the formation of a thick white plaque on the anterior surface of the IOL that prevented observation of the retina and the optic disc. His CDVA at this time was 1/200. Systemic therapy with fluconazole (400mg/day) and amphotericin B 0.15% eyedrops (six times per day) was started, which led to progressive reduction of the exudation in the anterior chamber. One week later, Acremonium falciforme species were identified in cultures obtained from samples, and the systemic therapy was switched to intravenous voriconazole 6mg/kg every 12 hours for the first day, then 4mg/kg intravenously every 12 hours for 10 days, followed by 200mg orally every 12 hours. This therapy led to a further reduction of the exudation in the anterior chamber. After seven days, it was possible to evaluate the red reflex of the retina, which revealed a slight improvement of CDVA to 1/60.Ten days later, the patient presented with liver function test impairment and sharp pain in the left orbital region that radiated to the same side of the head due to extension of the inflammatory process to the orbit and peri-orbital tissue. A magnetic resonance imaging (MRI) scan showed that there was evidence of left orbital inflammation with inhomogeneous appearance of the eyeball and peri-bulbar inflammation, which was more evident at the lacrimal gland . A faint hyperintensity of the optic nerve in T2 and slight signs of inflammation at the apex of the left orbital cavity were reported . At this time, therapy with systemic diclofenac and oral prednisone (25mg twice daily for two weeks) was started, which led to significant pain reduction. The condition of the left eye showed a gradual further improvement, but it was necessary to stop the systemic antifungal therapy after 22 days because of liver toxicity. The topical drugs were continued unchanged. One month later, unremitting pain in the orbital region reappeared; therefore, systemic antifungal therapy (voriconazole 6mg/kg intravenously every 12 hours for the first day, then 4mg/kg intravenously every 12 hours for 10 days, followed by 200mg orally every 12 hours) combined with pain therapy (acetaminophen 500mg/, codeine 30mg/day and gabapentin 300mg/day) was restarted, which led to progressive reduction of the patient’s ocular and peri-orbital pain.Immediately after this therapy, the patient showed significant ingravescent neurologic symptoms with visual hallucinations, postural instability, slight ideomotor slowdown, retropulsion and dynamic ataxia. Brain MRI excluded vascular lesions, but this examination highlighted enhancement of the left temporal muscle associated with ectasia of contiguous vessels, it was an evident index of inflammation . His electroencephalography results were normal, and lumbar puncture was performed to exclude infectious processes of the brain. Cerebrospinal fluid was clear, but showed albumin cytological dissociation. Once infectious or inflammatory processes were excluded, the cause of neurological symptoms was attributed to a toxic effect induced by the recently introduced analgesic therapy. After one week, we observed an improvement in neurologic symptomatology, but it was indispensable to maintain therapy with paracetamol, codeine and gabapentin. During this period, while the patient’s left eye began to show signs of phthisis, CDVA in his right eye decreased to 20/100 due to worsening of the cataract that was associated with progressive impairment of the optic nerve.After three months, voriconazole was suspended because of an increase in the cholestasis and hepatic cytolysis indices, but topical therapy was maintained for nine months. During this period, the patient was observed with close follow-up. He had no more signs of ocular inflammation; however, the white plaque on the anterior surface of the IOL did not disappear , and his pain was controlled with decreasing doses of analgesic oral therapy. The left eye’s condition deteriorated slowly into phthisis.", + "fulltext_subclaims": [ + "The patient was a 68-year-old Caucasian man.", + "He had glaucoma and was receiving chronic therapy.", + "He was referred with a diagnosis of post-operative endophthalmitis in the left eye.", + "He had inflammation in the left eye that had started a few days earlier.", + "The inflammation was associated with impaired vision.", + "Two weeks before presentation, he had undergone cataract surgery combined with a glaucoma shunt implant at another eye clinic.", + "Upon presentation, he had a corrected distance visual acuity (CDVA) of 20/80 in the right eye.", + "He had a cortical and nuclear cataract in the right eye.", + "He had a filtering bleb in the right eye.", + "The filtering bleb had developed after previous glaucoma surgery.", + "The previous glaucoma surgery had been performed two years earlier.", + "A glaucomatous optic disc excavation was present.", + "The visual field was significantly narrowed in the inferior nasal area.", + "He was receiving therapy with bimatoprost eyedrops in the right eye.", + "His CDVA in the left eye was 1/200.", + "He showed marked conjunctival injection.", + "He showed corneal edema.", + "He showed inflammatory aqueous cells (Tyndall 3+).", + "He showed fibrin on the front face of the intra-ocular lens (IOL).", + "The glaucoma shunt implant was in site.", + "The glaucoma shunt implant was an EX-PRESS® Glaucoma Filtration Device.", + "The filtering bleb was non-inflamed.", + "There was dense vitritis.", + "It was impossible to visualize the retina and the optic disc.", + "A 25-gauge pars plana vitrectomy (PPV) was performed.", + "The vitrectomy was performed using a CONSTELLATION® vitrectomy system.", + "Infusion fluid was devoid of any antibiotics.", + "Three trocars were inserted at a site 4.0mm from and parallel to the limbus.", + "The trocars were inserted at a 30° angle.", + "A vitreous sample was collected using the vitrectome.", + "The vitreous cavity was filled with silicone oil.", + "Ceftazidime and vancomycin were injected intravitreally.", + "All the sclerotomies were sutured.", + "During surgery, the retina appeared to be covered by an abundant fibrinous exudation.", + "After surgery, the patient’s CDVA was 1/30.", + "Therapy with topical vancomycin (50mg/ml) eyedrops six times per day was started.", + "Therapy with topical ceftazidime (50mg/ml) eyedrops six times per day was started.", + "The IOL and the glaucoma valve were left in place.", + "The patient strongly expressed the desire to leave the IOL and the glaucoma valve in place.", + "Cultures taken from the aqueous and vitreous were negative.", + "The early post-operative course was uneventful.", + "There were no signs of significant inflammation after surgery.", + "There was a thin layer of fibrin on the front face of the IOL.", + "He was discharged five days after surgery.", + "He continued the therapy at home.", + "He returned for scheduled checks.", + "During these checks, his CDVA was 1/20.", + "There were no signs of inflammation in the anterior chamber.", + "The retina could not be easily evaluated.", + "The inability to evaluate the retina was due to fibrin plaque on the surface of the IOL.", + "Forty-five days after surgery, he experienced acute, increasing pain in the left eye.", + "He had severe inflammation.", + "He had corneal edema.", + "He had anterior chamber inflammation (Tyndall 4+).", + "He had hypopyon occupying three-fourths of the anterior chamber.", + "He underwent a new anterior chamber washout with aqueous sample.", + "He underwent a vitrectomy with silicone oil tamponade.", + "Two days after his second surgery, an increase of intra-ocular pressure was observed.", + "The intra-ocular pressure increase was treated with topical and systemic therapy.", + "A thick white plaque formed on the anterior surface of the IOL.", + "The plaque prevented observation of the retina and the optic disc.", + "His CDVA at this time was 1/200.", + "Systemic therapy with fluconazole (400mg/day) was started.", + "Systemic therapy with amphotericin B 0.15% eyedrops (six times per day) was started.", + "This therapy led to a progressive reduction of the exudation in the anterior chamber.", + "One week later, Acremonium falciforme species were identified in cultures.", + "Systemic therapy was switched to intravenous voriconazole 6mg/kg every 12 hours for the first day.", + "Systemic therapy was then 4mg/kg intravenously every 12 hours for 10 days.", + "Systemic therapy was then 200mg orally every 12 hours.", + "This therapy led to a further reduction of the exudation in the anterior chamber.", + "After seven days, it was possible to evaluate the red reflex of the retina.", + "The red reflex showed a slight improvement of CDVA to 1/60.", + "Ten days later, the patient presented with liver function test impairment.", + "He had sharp pain in the left orbital region.", + "The pain radiated to the same side of the head.", + "The pain was due to extension of the inflammatory process to the orbit and peri-orbital tissue.", + "MRI showed evidence of left orbital inflammation.", + "MRI showed inhomogeneous appearance of the eyeball.", + "MRI showed peri-bulbar inflammation.", + "MRI showed more evident inflammation at the lacrimal gland.", + "MRI showed faint hyperintensity of the optic nerve in T2.", + "MRI showed slight signs of inflammation at the apex of the left orbital cavity.", + "Therapy with systemic diclofenac and oral prednisone (25mg twice daily for two weeks) was started.", + "This therapy led to significant pain reduction.", + "The condition of the left eye showed a gradual further improvement.", + "It was necessary to stop the systemic antifungal therapy after 22 days.", + "The systemic antifungal therapy was stopped due to liver toxicity.", + "The topical drugs were continued unchanged.", + "One month later, unremitting pain in the orbital region reappeared.", + "Systemic antifungal therapy (voriconazole 6mg/kg intravenously every 12 hours for the first day) was restarted.", + "Systemic antifungal therapy was then 4mg/kg intravenously every 12 hours for 10 days.", + "Systemic antifungal therapy was then 200mg orally every 12 hours.", + "Pain therapy (acetaminophen 500mg/day, codeine 30mg/day, and gabapentin 300mg/day) was started.", + "This therapy led to progressive reduction of the patient’s ocular and peri-orbital pain.", + "Immediately after this therapy, the patient showed significant ingravescent neurologic symptoms.", + "The neurologic symptoms included visual hallucinations.", + "The neurologic symptoms included postural instability.", + "The neurologic symptoms included slight ideomotor slowdown.", + "The neurologic symptoms included retropulsion.", + "The neurologic symptoms included dynamic ataxia.", + "Brain MRI excluded vascular lesions.", + "Brain MRI highlighted enhancement of the left temporal muscle.", + "Brain MRI showed ectasia of contiguous vessels.", + "The enhancement of the left temporal muscle was an evident index of inflammation.", + "Electroencephalography results were normal.", + "Lumbar puncture was performed to exclude infectious processes of the brain.", + "Cerebrospinal fluid was clear.", + "Cerebrospinal fluid showed albumin cytological dissociation.", + "Once infectious or inflammatory processes were excluded, the cause of neurological symptoms was attributed to a toxic effect induced by the recently introduced analgesic therapy.", + "After one week, an improvement in neurologic symptomatology was observed.", + "It was indispensable to maintain therapy with paracetamol, codeine, and gabapentin.", + "During this period, the patient’s left eye began to show signs of phthisis.", + "CDVA in his right eye decreased to 20/100.", + "The decrease in CDVA in the right eye was due to worsening of the cataract.", + "The decrease in CDVA in the right eye was associated with progressive impairment of the optic nerve.", + "After three months, voriconazole was suspended.", + "Voriconazole was suspended due to an increase in the cholestasis and hepatic cytolysis indices.", + "Topical therapy was maintained for nine months.", + "The patient was observed with close follow-up.", + "He had no more signs of ocular inflammation.", + "The white plaque on the anterior surface of the IOL did not disappear.", + "His pain was controlled with decreasing doses of analgesic oral therapy.", + "The left eye’s condition deteriorated slowly into phthisis." + ], + "summary": "A 68-year-old Caucasian man with glaucoma presented with endophthalmitis characterized by pain, redness and impaired vision in the left eye fifteen days after combined cataract and filtering surgery. He subsequently underwent a pars plana vitrectomy, with vitreous sampling, silicone oil placement and intra-vitreal injection of antibiotics, but only after a second vitrectomy we identified Acremonium falciforme as the causative agent for the endophthalmitis. An antifungal systemic and topical therapy was started, but meanwhile the infection extended to orbital and peri-orbital tissues. Following these procedures, even if the eye went slowly in phthisis, we were able to limit the further extension and circumscribe the orbital and extra-orbital involvement.", + "summary_subclaims": [ + "The patient is a 68-year-old Caucasian man.", + "The patient has glaucoma.", + "The patient presented with endophthalmitis.", + "The endophthalmitis was characterized by pain, redness, and impaired vision in the left eye.", + "The endophthalmitis occurred fifteen days after combined cataract and filtering surgery.", + "The patient underwent a pars plana vitrectomy.", + "Vitreous sampling was performed.", + "Silicone oil was placed.", + "An intra-vitreal injection of antibiotics was administered.", + "A second vitrectomy was performed.", + "Acremonium falciforme was identified as the causative agent for the endophthalmitis.", + "Antifungal systemic and topical therapy was started.", + "The infection extended to orbital and peri-orbital tissues.", + "The eye went slowly into phthisis.", + "The further extension of the infection was limited.", + "The orbital and extra-orbital involvement was circumscribed." + ] + }, + { + "id": "multiclinsum_test_2380_en.txt", + "fulltext": "A 60-year-old female with a medical history of hypertension presented to the orthopedic foot and ankle clinic with progressive pain about her right first MTPJ. She reported having a first MTPJ arthroplasty in 2004 and long-standing pain in her first MTPJ that worsened with walking. She had attempted a Morton’s extension orthotic without pain relief.\nOn physical examination, there was tenderness to palpation about the first MTPJ, with mild swelling and a well-healed dorsal surgical scar. Range of motion of the joint was painful through the entire arc of motion. There was also tenderness to palpation on the plantar aspect of the second and third MTPJs, with corresponding plantar-based calluses, but normal sensation throughout the foot, with palpable pedal pulses, and brisk capillary refill in all toes.\nThree-view radiographic evaluation of the right foot showed a prior first MTPJ arthroplasty with perihardware lucency indicative of loosening components and a shortened first ray. The patient was diagnosed with failed first MTPJ arthroplasty secondary to loosening of the components, with concomitant second and third transfer metatarsalgia. After discussing treatment options, the patient chose to undergo surgical intervention involving hardware removal and first MTPJ arthrodesis, along with second and third metatarsal head Weil osteotomies to address her metatarsalgia. Her pre-operative metatarsophalangeal-interphalangeal (MTP-IP) score was 39.\nIn the operating room, an incision was made through her prior dorsal surgical incision. Dissection was carried down to the first MTPJ arthroplasty. The components were grossly loose and were removed without difficulty. Curettes and a drill bit were used to debride the intramedullary portion of the distal first metatarsal and the proximal aspect of the proximal phalanx . A 2-cm bone gap was identified, and inadequate bone stock remained in the proximal phalanx to allow for hardware fixation. A decision was made to proceed with arthrodesis without the use of hardware. Ten cc of bone marrow was aspirated from the proximal tibia and mixed with a bone substitute (NovoGro®, Osteonovus, Toledo, Ohio) for later use. Fibular strut allograft with adequate length to fill the bone void was measured under fluoroscopy and cut to appropriate size to hold the toe out to length. Traction was applied to the toe, and the strut grafts were placed across the joint and within the medullary canal of the first metatarsal and then the proximal phalanx . The strut graft provided stability to the joint through its tensile effect. The bone graft substitute was packed into the proximal phalanx, first metatarsal head, and remaining first MTPJ space . Weil osteotomies were performed on the second and third metatarsal heads through separate dorsal incisions to restore a normal cascade. The patient was placed in a posterior, short-leg splint postoperatively and made non-weight bearing.\nAt her 2-week follow-up, she was transitioned to a short-leg cast and continued her weight bearing restrictions. Radiographs at 1 month showed callus formation and graft consolidation at the first MTPJ . The patient was transitioned to a fracture boot at 6 weeks, but was kept non-weight bearing until 3 months postoperatively. At her 3-month follow-up, the patient was transitioned to a forefoot rocker sole shoe with carbon plate insert and allowed to weight bear as tolerated. She reported no pain in her great toe. A computed tomography scan was obtained at 4 months postoperatively, which showed continued consolidation of the fusion. At 5 months postoperatively, the patient was back to wearing her normal shoes and reported no activity limitations, including jogging. At 2 years postoperatively, she reported no pain in the toe and was completely satisfied with the procedure. Her final MTP-IP score was 83.", + "fulltext_subclaims": [ + "The patient is a 60-year-old female.", + "She has a medical history of hypertension.", + "She presented to the orthopedic foot and ankle clinic.", + "She had a first MTPJ arthroplasty in 2004.", + "She reported long-standing pain in her first MTPJ.", + "The pain worsened with walking.", + "She had attempted a Morton’s extension orthotic without pain relief.", + "On physical examination, there was tenderness to palpation about the first MTPJ.", + "There was mild swelling about the first MTPJ.", + "There was a well-healed dorsal surgical scar.", + "Range of motion of the first MTPJ was painful through the entire arc.", + "There was tenderness to palpation on the plantar aspect of the second and third MTPJs.", + "There were plantar-based calluses on the second and third MTPJs.", + "Sensation throughout the foot was normal.", + "Pedal pulses were palpable.", + "Capillary refill was brisk in all toes.", + "Radiographic evaluation showed a prior first MTPJ arthroplasty.", + "Perihardware lucency was indicative of loosening components.", + "The first ray was shortened.", + "The patient was diagnosed with failed first MTPJ arthroplasty.", + "The failure was secondary to loosening of the components.", + "She had concomitant second and third transfer metatarsalgia.", + "She chose to undergo surgical intervention.", + "The surgical intervention included hardware removal and first MTPJ arthrodesis.", + "Weil osteotomies were planned for the second and third metatarsal heads.", + "Her pre-operative MTP-IP score was 39.", + "An incision was made through her prior dorsal surgical incision.", + "The components were grossly loose.", + "The components were removed without difficulty.", + "A 2-cm bone gap was identified.", + "Inadequate bone stock remained in the proximal phalanx.", + "A decision was made to proceed with arthrodesis without hardware.", + "Ten cc of bone marrow was aspirated from the proximal tibia.", + "The bone marrow was mixed with a bone substitute (NovoGro®).", + "A fibular strut allograft was measured under fluoroscopy.", + "The strut graft was cut to appropriate size.", + "The strut graft was placed across the joint and within the medullary canal.", + "The bone graft substitute was packed into the proximal phalanx.", + "The bone graft substitute was packed into the first metatarsal head.", + "The bone graft substitute was packed into the remaining first MTPJ space.", + "Weil osteotomies were performed on the second and third metatarsal heads.", + "The patient was placed in a posterior, short-leg splint postoperatively.", + "She was made non-weight bearing.", + "At 2 weeks, she was transitioned to a short-leg cast.", + "Radiographs at 1 month showed callus formation.", + "Radiographs at 1 month showed graft consolidation at the first MTPJ.", + "At 6 weeks, she was transitioned to a fracture boot.", + "She was kept non-weight bearing until 3 months postoperatively.", + "At 3 months, she was transitioned to a forefoot rocker sole shoe.", + "She was allowed to weight bear as tolerated.", + "She reported no pain in her great toe.", + "A computed tomography scan at 4 months showed continued consolidation.", + "At 5 months, she was back to wearing her normal shoes.", + "She reported no activity limitations.", + "At 2 years postoperatively, she reported no pain in the toe.", + "She was completely satisfied with the procedure.", + "Her final MTP-IP score was 83." + ], + "summary": "A 60-year-old women presented to us with first MTPJ pain in the setting of failed arthroplasty. We performed an arthrodesis; however, intraoperatively, hardware fixation could not be obtained due to bone loss. We utilized allograft bone struts to maintain first ray length and to hold the correct hallux position during arthrodesis maturation.", + "summary_subclaims": [ + "The patient is a 60-year-old woman.", + "The patient presented with first MTPJ pain.", + "The pain was in the setting of failed arthroplasty.", + "We performed an arthrodesis.", + "Intraoperatively, hardware fixation could not be obtained due to bone loss.", + "We utilized allograft bone struts.", + "The allograft bone struts were used to maintain first ray length.", + "The allograft bone struts were used to hold the correct hallux position during arthrodesis maturation." + ] + }, + { + "id": "multiclinsum_test_2295_en.txt", + "fulltext": "A 48-year-old man experienced a sudden onset of seizures in his left lower limb. He had never previously experienced such an episode. Gadolinium-enhanced MRI (Gd-MRI) revealed a small, homogenous-enhancing mass in the peripheral aspect of the right parieto-frontal lobe. The patient was referred to our hospital for further evaluation. The results of the physical examination performed at the time of admission were unremarkable. No cutaneous stigmata of neurofibromatosis Type I was observed. A neurological examination revealed no significant findings.\nThe lesion appeared as a well-defined, isosignal intensity area on T1-weighted MRI , was hyperintense on T2-weighted MRI , and also hyperintense on fluid attenuation inversion recovery MRI . The lesion demonstrated homogenous enhancement on Gd-T1-weighted MRI [-]. Curvilinear enhancement was observed beneath the parietal bone but was unlikely to represent a “dural tail sign;” however, these findings are similar to convexity meningioma. T2-weighted MRI showed definite evidence of perilesional edema. Digital subtraction angiography showed some feeding arteries (right middle cerebral artery branch) [ and ], right anterior cerebral artery branch [ and ], and right middle meningeal artery (MMA) branch [ and ]. Preoperative feeder embolization targeted to the right MMA branch was performed [ and ].\nOur preoperative diagnosis was an extra-axial tumor, such as convexity meningioma or other tumors. A whole-body evaluation revealed no evidence of malignancy. The patient underwent a parietal craniotomy, with total resection of the tumor. During surgery, tumoral invasion beyond the dura mater was observed . When the dura was opened, a well-demarcated, firm, spherical tumor was observed beneath the arachnoid membrane. The tumor was elastic, hard, grayish in color, and loosely adherent to but separable from the dura mater . The tumor was totally removed piece by piece, with the adjacent brain tissue and dura . Postoperative MRI showed the total removal of the tumor [-]. The postoperative course was uneventful, and the patient was discharged without neurological deficits.\nIn light-microscopic assessments, the tumor was composed predominantly of Antoni Type A, and intermingled with Antoni Type B . Immunohistochemical staining was positive for S-100 protein but negative for glial fibrillary acidic protein, cluster of differentiation 34, epithelial membrane antigen , signal transducer and activator of transcription 6 , progesterone receptor, and synaptophysin. The histopathological diagnosis was schwannoma. The tumor was observed to be in the subarachnoid space extending to outer space of dura mater, intimately attached to the pia mater [ and ]. Electron-microscopic studies were not performed.", + "fulltext_subclaims": [ + "The patient is a 48-year-old man.", + "He experienced a sudden onset of seizures in his left lower limb.", + "He had never previously experienced such an episode.", + "Gadolinium-enhanced MRI (Gd-MRI) revealed a small, homogenous-enhancing mass in the peripheral aspect of the right parieto-frontal lobe.", + "The patient was referred to our hospital for further evaluation.", + "The results of the physical examination performed at the time of admission were unremarkable.", + "No cutaneous stigmata of neurofibromatosis Type I was observed.", + "A neurological examination revealed no significant findings.", + "The lesion appeared as a well-defined, isosignal intensity area on T1-weighted MRI.", + "The lesion was hyperintense on T2-weighted MRI.", + "The lesion was hyperintense on fluid attenuation inversion recovery MRI.", + "The lesion demonstrated homogenous enhancement on Gd-T1-weighted MRI.", + "Curvilinear enhancement was observed beneath the parietal bone.", + "These findings are similar to convexity meningioma.", + "T2-weighted MRI showed definite evidence of perilesional edema.", + "Digital subtraction angiography showed some feeding arteries.", + "Digital subtraction angiography showed a right middle cerebral artery branch.", + "Digital subtraction angiography showed a right anterior cerebral artery branch.", + "Digital subtraction angiography showed a right middle meningeal artery branch.", + "Preoperative feeder embolization targeted to the right MMA branch was performed.", + "Our preoperative diagnosis was an extra-axial tumor, such as convexity meningioma or other tumors.", + "A whole-body evaluation revealed no evidence of malignancy.", + "The patient underwent a parietal craniotomy, with total resection of the tumor.", + "During surgery, tumoral invasion beyond the dura mater was observed.", + "When the dura was opened, a well-demarcated, firm, spherical tumor was observed beneath the arachnoid membrane.", + "The tumor was elastic, hard, grayish in color, and loosely adherent to but separable from the dura mater.", + "The tumor was totally removed piece by piece, with the adjacent brain tissue and dura.", + "Postoperative MRI showed the total removal of the tumor.", + "The postoperative course was uneventful.", + "The patient was discharged without neurological deficits.", + "In light-microscopic assessments, the tumor was composed predominantly of Antoni Type A.", + "In light-microscopic assessments, the tumor was intermingled with Antoni Type B.", + "Immunohistochemical staining was positive for S-100 protein.", + "Immunohistochemical staining was negative for glial fibrillary acidic protein.", + "Immunohistochemical staining was negative for cluster of differentiation 34.", + "Immunohistochemical staining was negative for epithelial membrane antigen.", + "Immunohistochemical staining was negative for signal transducer and activator of transcription 6.", + "Immunohistochemical staining was negative for progesterone receptor.", + "Immunohistochemical staining was negative for synaptophysin.", + "The histopathological diagnosis was schwannoma.", + "The tumor was observed to be in the subarachnoid space extending to outer space of dura mater.", + "The tumor was intimately attached to the pia mater.", + "Electron-microscopic studies were not performed." + ], + "summary": "A 48-year-old man presented with a sudden onset of seizures. Brain magnetic resonance image (MRI) revealed a small mass lesion in the peripheral aspect of the right parieto-frontal lobe. The mass was isointense on T1-weighted and hyperintense on T2-weighted MRI, with homogenous enhancement after contrast medium administration. After the feeder embolization on the previous day, removal of the tumor was performed. The tumor revealed a well-demarcated, firm, spherical tumor beyond, and beneath the dura and was relatively easy to be separated from the brain. Histologically, the tumor was observed to be in subarachnoid space extending to outer space of dura-mater, intimately attached to the pia mater. The histological diagnosis was schwannoma.", + "summary_subclaims": [ + "A 48-year-old man presented with a sudden onset of seizures.", + "Brain magnetic resonance image (MRI) revealed a small mass lesion in the peripheral aspect of the right parieto-frontal lobe.", + "The mass was isointense on T1-weighted MRI.", + "The mass was hyperintense on T2-weighted MRI.", + "The mass showed homogenous enhancement after contrast medium administration.", + "Feeder embolization was performed on the previous day.", + "Removal of the tumor was performed.", + "The tumor was well-demarcated, firm, and spherical.", + "The tumor was beyond and beneath the dura.", + "The tumor was relatively easy to be separated from the brain.", + "Histologically, the tumor was observed to be in subarachnoid space extending to outer space of dura-mater.", + "The tumor was intimately attached to the pia mater.", + "The histological diagnosis was schwannoma." + ] + }, + { + "id": "multiclinsum_test_3174_en.txt", + "fulltext": "A 61-year-old Bedouin man presented to a local hospital in September 2021 with a history of a black scorpion sting to his right eye, when he suddenly felt severe pain in his right eye and flanks along with loss of consciousness. He was subsequently admitted to the intensive care unit until his case improved. The scorpion was later found hidden within his clothes, identified as Androctonus crassicauda, commonly known as the Arabian fat-tailed scorpion, a type of arachnid that is widespread in the desert of Jordan.\n\nInitial Ocular Presentation: February–March 2022\nTwo days after the bite, the patient described having severe tearing pain in the right eye, headache and loss of vision that lasted later for a month. Subsequently, he sought medical treatment from five different private ophthalmologists without improvement. Consequently, the patient was referred to our tertiary ophthalmic center, and he had been on atropine 1% eye drops twice daily, moxifloxacin eye drops 0.5% four times a day, acyclovir eye ointment 5% four times a day, oral acyclovir 400 mg four times a day, and oral Levofloxacin 500mg once a day.\n\nUpon examination at our center, the patient was presented with visual acuity of counting fingers close in the right eye, crescent-shaped epithelial defect, central corneal thinning surrounded by infiltrate (5mmx5mm), severe ciliary injection and hypopyon (3mm), all consistent with signs of keratitis. The treatment plan was modified as follows: the initial treatment plan was maintained with atropine 1% twice daily - and oral levofloxacin 500mg once a day, while the frequency of oral acyclovir 400 mg was increased to 5 times/day. Newly added medications included fortified vancomycin eye drops 5% every hour, fortified amikacin eye drop 2.5% every hour and lubricant eye drops every 1 hour. Topical moxifloxacin and acyclovir ointment were discontinued, and the patient was discharged with a follow-up appointment scheduled after 2 days.\n\nTwo days later, the patient returned to the outpatient clinic with a deterioration in vision, presented with a visual acuity of hand motion. There was no improvement in clinical signs, including a hypopyon of 2.5 mm, a large central ulcer with thinning, ciliary injection, and mild eyelid swelling. Consequently, the patient was admitted to the inpatient department. After 3 days of no improvement, amphotericin-b fortified eye drops 0.15% were added every hour, alternating with fortified vancomycin 5% and amikacin 2.5% every hour. One-week post-admission, clinical examination revealed a 1.5 mm hypopyon and a corneal ulcer. Antibiotics were discontinued to obtain an eye swab and fungal cultures, which returned negative. Treatment was adjusted, changing the frequency of fortified antibiotics every 4 hours (amikacin 2.5%, vancomycin 5%, amphotericin b 0.15%). Loteprednol etabonate 0.5%, and chloramphenicol eye ointment 1% were then added to the treatment plan 1 week later.\n\nThree weeks after presentation, his exam revealed a visual acuity of counting fingers close in his right eye, hypopyon 2 mm, ciliary injection, and a large area of infiltrates with an overlying epithelial defect. All fortified antibiotics and antifungal eye drops were discontinued after the corneal ulcer improved, with a significant reduction in symptoms, including less pain. The patient was maintained on lubricant eye drops every 2 hours, moxifloxacin 0.5% eye drops 6 times/day, chloramphenicol eye ointment 1%, and atropine 1% every 12 hours. Despite the improvement, the patient was not yet discharged due to the need for continued monitoring and treatment.\n\nAt discharge, the corneal ulcer continued to show signs of improvement, with resolved hypopyon, formation of a scar overlying the corneal infiltrate and reduced ciliary injection with a visual acuity of 20/60 for the patient was discharged on lubricants every hour, cyclopentolate 1% every 12 hours, loteprednol etabonate 0.5% every 12 hours, moxifloxacin 0.5% 4 times/day, and chloramphenicol ointment 1% at bed time.\n\nSix months later (August 2022), he returned for a follow-up appointment with opacity in the right eye and old vascularization, but no signs of infection. His visual acuity was 20/100. He was maintained on loteprednol etabonate 0.5%, moxifloxacin 0.5%, and lubricating eye drops.\n\nLast Presentation (July–September 2023)\nIn July 2023, the patient reported a gradual loss of vision in his right eye exacerbated by one heat wave, accompanied by right-sided headaches, burning sensation, itching, diplopia, tears, tinnitus and heat-induced severe pain. On July 31st, 25 days after the onset of symptoms, he presented to the hospital with another attack of keratitis in the right eye.\n\nOphthalmic examination of the right eye revealed visual acuity of Hand motion. Anterior segment exam revealed central scar with an overlying epithelial defect 3mm*4mm with corneal neovascularization in the right eye. Initially, the patient was treated with fortified vancomycin 5% every hour, alternating with fortified amikacin 2.5%.\n\nOn the 3rd of August, he presented again for follow-up with a visual acuity of hand motion, a central corneal scar with an overlying epithelial defect measuring 3 mm × 5 mm, and 360-degree corneal vascularization. The patient complained of irritation attributed to the fortified antibiotic eye drops. Consequently, fortified vancomycin and amikacin were discontinued, moxifloxacin was increased to once every hour, and chloramphenicol ointment was added. Nonetheless, on August 7th, his visual acuity remained hand motion. He additionally had a 0.5 mm hypopyon, a large ring corneal abscess, and an epithelial defect measuring 3 mm × 5 mm. As a result of these findings, he was diagnosed with recurrent fungal keratitis. His treatment plan was adjusted accordingly to include lubricant eye drops every 2 hours and fortified voriconazole 1% eye drops four times a day, due to the unavailability of amphotericin B. On 11th of August, his visual acuity was still hand motion, and examination revealed a ciliary injection and an epithelial defect measuring 3 mm × 3mm. The hypopyon had increased to 2 mm. As a result, all antibiotics were held, and cultures were taken again, which also came back negative. After culture collection, the patient was restarted on fortified voriconazole eye drops 8 times a day, moxifloxacin eye drops every hour, and lubricants every hour. Moreover, oral fluconazole 400 mg was given as a loading dose, followed by 200 mg once daily as maintenance.\n\nOn 25th of August, his visual acuity improved to counting fingers at 3 meters with resolution of the hypopyon and an ulcer size of 2 mm × 3mm. Oral doxycycline 100 mg once daily, and loteprednol etabonate eye drops 0.5% every 2 hours were added. Voriconazole and moxifloxacin eye drops were decreased to 4 times a day. The patient's case was monitored over 3 days.\n\nThe patient’s case continued to improve until 27th September 2023 when he was discharged. Upon examination, his visual acuity was 20/125, and the ulcer had resolved, leaving a 3 mm*4 mm scar with no fluorescein uptake. Discharge medications included fortified voriconazole eye drops 1% twice a day, moxifloxacin eye drops 0.5% twice a day, lubricants eye drops every 2 hours, loteprednol etabonate eye drops 0.5% four times a day, cyclopentolate eye drops 1% twice a day, and oral doxycycline 100 mg once daily for 1 week, with eye drops administered only to his right eye. A follow-up appointment was scheduled 2 weeks later post-discharge.\n\nDuring the follow-up appointment, examination revealed a visual acuity 20/200. The patient had a central scar measuring 3 mm × 4mm, corneal thinning, and vascularization. Moxifloxacin 0.5% and loteprednol etabonate 0.5% eye drops were reduced to twice daily, while lubricants were continued. Cyclopentolate 1% and fortified voriconazole 1% eye drops were discontinued. The patient was planned for corneal transplantation.", + "fulltext_subclaims": [ + "The patient is a 61-year-old Bedouin man.", + "He presented to a local hospital in September 2021.", + "He had a history of a black scorpion sting to his right eye.", + "He suddenly felt severe pain in his right eye and flanks.", + "He experienced loss of consciousness.", + "He was admitted to the intensive care unit.", + "The scorpion was identified as Androctonus crassicauda.", + "The scorpion is commonly known as the Arabian fat-tailed scorpion.", + "The scorpion was found hidden within his clothes.", + "The scorpion is widespread in the desert of Jordan.", + "Two days after the bite, the patient described having severe tearing pain in the right eye.", + "He had headache and loss of vision that lasted for a month.", + "He sought medical treatment from five different private ophthalmologists.", + "He was referred to a tertiary ophthalmic center.", + "He was on atropine 1% eye drops twice daily.", + "He was on moxifloxacin eye drops 0.5% four times a day.", + "He was on acyclovir eye ointment 5% four times a day.", + "He was on oral acyclovir 400 mg four times a day.", + "He was on oral Levofloxacin 500mg once a day.", + "Upon examination, the patient had visual acuity of counting fingers close in the right eye.", + "He had a crescent-shaped epithelial defect.", + "He had central corneal thinning surrounded by infiltrate (5mmx5mm).", + "He had severe ciliary injection.", + "He had hypopyon (3mm).", + "The treatment plan included atropine 1% twice daily.", + "The treatment plan included oral levofloxacin 500mg once a day.", + "The frequency of oral acyclovir 400 mg was increased to 5 times/day.", + "Fortified vancomycin eye drops 5% were added every hour.", + "Fortified amikacin eye drops 2.5% were added every hour.", + "Lubricant eye drops were added every 1 hour.", + "Topical moxifloxacin and acyclovir ointment were discontinued.", + "The patient was discharged with a follow-up appointment scheduled after 2 days.", + "Two days later, the patient returned with deterioration in vision.", + "He had visual acuity of hand motion.", + "There was no improvement in clinical signs.", + "He had a hypopyon of 2.5 mm.", + "He had a large central ulcer with thinning.", + "He had ciliary injection.", + "He had mild eyelid swelling.", + "The patient was admitted to the inpatient department.", + "After 3 days of no improvement, amphotericin-b fortified eye drops 0.15% were added every hour.", + "Amphotericin-b was alternating with fortified vancomycin 5% and amikacin 2.5% every hour.", + "One-week post-admission, clinical examination revealed a 1.5 mm hypopyon.", + "One-week post-admission, clinical examination revealed a corneal ulcer.", + "Antibiotics were discontinued to obtain an eye swab and fungal cultures.", + "Fungal cultures returned negative.", + "Treatment was adjusted to include fortified antibiotics every 4 hours.", + "Loteprednol etabonate 0.5% was added.", + "Chloramphenicol eye ointment 1% was added.", + "Three weeks after presentation, visual acuity was counting fingers close in the right eye.", + "He had a hypopyon 2 mm.", + "He had a large area of infiltrates with an overlying epithelial defect.", + "All fortified antibiotics and antifungal eye drops were discontinued.", + "The patient was maintained on lubricant eye drops every 2 hours.", + "The patient was maintained on moxifloxacin 0.5% eye drops 6 times/day.", + "The patient was maintained on chloramphenicol eye ointment 1%.", + "The patient was maintained on atropine 1% every 12 hours.", + "The patient was not yet discharged due to the need for continued monitoring and treatment.", + "At discharge, the corneal ulcer showed signs of improvement.", + "Hypopyon was resolved.", + "A scar formed overlying the corneal infiltrate.", + "Ciliary injection was reduced.", + "Visual acuity was 20/60.", + "The patient was discharged on lubricants every hour.", + "The patient was discharged on cyclopentolate 1% every 12 hours.", + "The patient was discharged on loteprednol etabonate 0.5% every 12 hours.", + "The patient was discharged on moxifloxacin 0.5% 4 times/day.", + "The patient was discharged on chloramphenicol ointment 1% at bedtime.", + "Six months later, he returned with opacity in the right eye.", + "He had old vascularization.", + "He had no signs of infection.", + "Visual acuity was 20/100.", + "He was maintained on loteprednol etabonate 0.5%.", + "He was maintained on moxifloxacin 0.5%.", + "He was maintained on lubricating eye drops.", + "In July 2023, the patient reported a gradual loss of vision in his right eye.", + "The loss of vision was exacerbated by one heat wave.", + "He had right-sided headaches.", + "He had a burning sensation.", + "He had itching.", + "He had diplopia.", + "He had tears.", + "He had tinnitus.", + "He had heat-induced severe pain.", + "On July 31st, he presented to the hospital with another attack of keratitis in the right eye.", + "Ophthalmic examination revealed visual acuity of hand motion.", + "Anterior segment exam revealed a central scar with an overlying epithelial defect 3mm*4mm.", + "He had corneal neovascularization in the right eye.", + "Initially, he was treated with fortified vancomycin 5% every hour.", + "Initially, he was treated with fortified amikacin 2.5%.", + "On the 3rd of August, visual acuity was hand motion.", + "He had a central corneal scar with an overlying epithelial defect measuring 3 mm × 5 mm.", + "He had 360-degree corneal vascularization.", + "He complained of irritation attributed to the fortified antibiotic eye drops.", + "Fortified vancomycin and amikacin were discontinued.", + "Moxifloxacin was increased to once every hour.", + "Chloramphenicol ointment was added.", + "On August 7th, visual acuity remained hand motion.", + "He had a 0.5 mm hypopyon.", + "He had a large ring corneal abscess.", + "He had an epithelial defect measuring 3 mm × 5 mm.", + "He was diagnosed with recurrent fungal keratitis.", + "His treatment plan included lubricant eye drops every 2 hours.", + "His treatment plan included fortified voriconazole 1% eye drops four times a day.", + "On 11th of August, visual acuity was still hand motion.", + "Examination revealed a ciliary injection.", + "Examination revealed an epithelial defect measuring 3 mm × 3mm.", + "The hypopyon had increased to 2 mm.", + "All antibiotics were held, and cultures were taken again.", + "Cultures came back negative.", + "After culture collection, the patient was restarted on fortified voriconazole eye drops 8 times a day.", + "Moxifloxacin eye drops were given every hour.", + "Lubricants were given every hour.", + "Oral fluconazole 400 mg was given as a loading dose.", + "Oral fluconazole 200 mg was given once daily as maintenance.", + "On 25th of August, visual acuity improved to counting fingers at 3 meters.", + "The hypopyon resolved.", + "The ulcer size was 2 mm × 3mm.", + "Oral doxycycline 100 mg was given once daily.", + "Loteprednol etabonate eye drops 0.5% were given every 2 hours.", + "Voriconazole and moxifloxacin eye drops were decreased to 4 times a day.", + "The patient's case was monitored over 3 days.", + "The patient’s case continued to improve until 27th September 2023.", + "Upon discharge, visual acuity was 20/125.", + "The ulcer had resolved, leaving a 3 mm*4 mm scar.", + "There was no fluorescein uptake.", + "Discharge medications included fortified voriconazole eye drops 1% twice a day.", + "Discharge medications included moxifloxacin eye drops 0.5% twice a day.", + "Discharge medications included lubricants eye drops every 2 hours.", + "Discharge medications included loteprednol etabonate eye drops 0.5% four times a day.", + "Discharge medications included cyclopentolate eye drops 1% twice a day.", + "Discharge medications included oral doxycycline 100 mg once daily for 1 week.", + "Eye drops were administered only to his right eye.", + "A follow-up appointment was scheduled 2 weeks later post-discharge.", + "During the follow-up appointment, visual acuity was 20/200.", + "The patient had a central scar measuring 3 mm × 4mm.", + "He had corneal thinning.", + "He had vascularization.", + "Moxifloxacin 0.5% and loteprednol etabonate 0.5% eye drops were reduced to twice daily.", + "Lubricants were continued.", + "Cyclopentolate 1% and fortified voriconazole 1% eye drops were discontinued.", + "The patient was planned for corneal transplantation." + ], + "summary": "We report the case of a previously healthy 61-year-old male who sustained a sting from an Androctonus crassicauda scorpion to his right eye. The patient was admitted to the intensive care unit (ICU) in a comatose state immediately after the sting. A few days later, he suffered from tearing right-eye pain and loss of vision, which persisted despite initial treatment. The patient was subsequently diagnosed with keratitis and admitted to King Abdullah University Hospital (KAUH). He was prescribed various antibiotics, which initially improved his condition. However, the patient experienced subsequent deterioration and recurrent episodes of keratitis. The patient’s visual acuity improved after treatment with a combination of antifungal and antibiotic medications, suggesting a polymicrobial infection. Despite the improvement in his condition, the sting left a central corneal scar, necessitating corneal transplant surgery as a definitive treatment.", + "summary_subclaims": [ + "The patient was a 61-year-old male.", + "The patient sustained a sting from an Androctonus crassicauda scorpion to his right eye.", + "The patient was admitted to the ICU in a comatose state immediately after the sting.", + "A few days later, he suffered from tearing right-eye pain.", + "A few days later, he suffered from loss of vision.", + "The patient was diagnosed with keratitis.", + "The patient was admitted to King Abdullah University Hospital.", + "The patient was prescribed various antibiotics.", + "The patient experienced subsequent deterioration.", + "The patient experienced recurrent episodes of keratitis.", + "The patient’s visual acuity improved after treatment with a combination of antifungal and antibiotic medications.", + "The sting left a central corneal scar.", + "Corneal transplant surgery was necessitated by the central corneal scar." + ] + }, + { + "id": "multiclinsum_test_503_en.txt", + "fulltext": "A 69 year old Caucasian female with a past history of ocular melanoma was found to have an incidental 1.6 × 1.6 × 0.7 cm hypodense lesion in the head of the pancreas, on surveillance computed tomographic (CT) scanning of the abdomen . In addition, there was a single enlarged porta hepatis lymph node measuring 2.8 × 1 cm. The patient was asymptomatic and without any prior episodes of pancreatitis.\nAdditional imaging studies were performed to characterize the lesion. Magnetic resonance imaging (MRI) demonstrated the 1.7 × 1.3 cm lobulated lesion with effacement of the distal CBD . Endoscopic ultrasound (EUS) confirmed the 1.5 × 1.4 cm hypoechoic lesion suggestive of a cyst, which did not show communication with the pancreatic duct. EUS further demonstrated thickened cyst wall with mural nodule and presence of luminal debris . The mural nodule measured 0.8 × 0.7 cm. Vascularity of the nodule on EUS was not assessed. Fine needle aspiration of the cyst revealed turbid, viscous fluid, however the pathology evaluation was inconclusive. Post-EUS, the patient developed right upper quadrant abdominal pain, with post-prandial worsening, and was associated with dark colored urine and acholic stools. Due to concern for extrinsic compression on the CBD, the patient underwent ERCP, which identified a 7 mm single area of stenosis in the CBD that was relieved with placement of a plastic stent. Following stent placement, her blood work and symptoms normalized. She underwent repeat EUS with FNA of mural nodule. The FNA cytologic evaluation revealed atypical cells. Clinically, the cyst was considered to be an intraductal papillary mucinous neoplasm or mucinous cystic neoplasm. Considering the worrisome features of lymphadenopathy on imaging studies and atypical cells on FNA cytology of mural nodule, a decision was made to resect the lesion. Pancreas protocol CT scan performed prior to surgery showed a vague hypodense area in the pancreatic head, likely collapse of the cyst following aspiration, and a decompressed biliary tree. Pancreatic duct was not dilated, however, there was distal pancreas atrophy. A pylorus preserving pancreaticoduodenectomy was performed.\nGross evaluation of the pancreas revealed a 1.6 × 1.1 × 1 cm uniloculated cystic lesion in the head of the pancreas. The cyst did not show communication with the main pancreatic duct. The cystic lesion was completely excised and all margins were negative. The entire lesion was submitted for histological evaluation. Microscopic evaluation showed a unilocular cyst lined by gastric type mucinous epithelium . No papillary projection or configuration was seen. Immunohistochemical stains showed the cyst wall lining to be diffusely positive for MUC5AC, and focally positive for MUC 6. The mucinous lining was negative for MUC1 and MUC2 . The histological features were consistent with a simple mucinous cyst. No dysplasia or carcinoma was seen. There was focal thickening in the cyst wall with intraluminal nodular lesion characterized by amorphous eosinophilic congophilic material consistent with amyloid, surrounded by foreign body type giant cell reaction and chronic inflammation composed of lymphocytes and polyclonal plasma cells . Upon further evaluation of congo red stain, the amyloid deposits showed characteristic apple green birefringence on polarizing microscopy, and red fluorescence on fluorescent microscopy using Texas Red filter . This focus correlated with the mural nodule seen on EUS. Laser microdissection (LMD)-liquid chromatography-tandem mass spectroscopy (LC–MS) confirmed the amyloid to be lactoferrin type. In addition, an immunostain for lactoferrin was positive in the amyloid deposits . The background pancreas showed mild chronic pancreatitis. No amyloid deposition was noted in the islets of Langerhans, interstitium or blood vessels of pancreas.\nHer post-operative course was uneventful apart from a mild wound seroma requiring only local wound care. She has since been seen multiple times in clinic following surgery and has recovered well.", + "fulltext_subclaims": [ + "The patient is a 69 year old Caucasian female.", + "She has a past history of ocular melanoma.", + "She was found to have an incidental 1.6 × 1.6 × 0.7 cm hypodense lesion in the head of the pancreas on surveillance CT scanning of the abdomen.", + "There was a single enlarged porta hepatis lymph node measuring 2.8 × 1 cm.", + "The patient was asymptomatic.", + "She had no prior episodes of pancreatitis.", + "MRI demonstrated a 1.7 × 1.3 cm lobulated lesion with effacement of the distal CBD.", + "EUS confirmed a 1.5 × 1.4 cm hypoechoic lesion suggestive of a cyst.", + "The cyst did not show communication with the pancreatic duct.", + "EUS demonstrated thickened cyst wall with mural nodule and presence of luminal debris.", + "The mural nodule measured 0.8 × 0.7 cm.", + "Vascularity of the nodule on EUS was not assessed.", + "Fine needle aspiration of the cyst revealed turbid, viscous fluid.", + "Pathology evaluation of the FNA was inconclusive.", + "Post-EUS, the patient developed right upper quadrant abdominal pain with post-prandial worsening.", + "The pain was associated with dark colored urine and acholic stools.", + "ERCP identified a 7 mm single area of stenosis in the CBD.", + "The stenosis was relieved with placement of a plastic stent.", + "Following stent placement, her blood work and symptoms normalized.", + "She underwent repeat EUS with FNA of mural nodule.", + "FNA cytologic evaluation revealed atypical cells.", + "The cyst was considered to be an intraductal papillary mucinous neoplasm or mucinous cystic neoplasm.", + "Worrisome features included lymphadenopathy on imaging studies and atypical cells on FNA cytology of mural nodule.", + "A decision was made to resect the lesion.", + "Pancreas protocol CT scan showed a vague hypodense area in the pancreatic head, likely collapse of the cyst following aspiration.", + "The pancreatic duct was not dilated.", + "There was distal pancreas atrophy.", + "A pylorus preserving pancreaticoduodenectomy was performed.", + "Gross evaluation revealed a 1.6 × 1.1 × 1 cm uniloculated cystic lesion in the head of the pancreas.", + "The cyst did not show communication with the main pancreatic duct.", + "The cystic lesion was completely excised and all margins were negative.", + "Microscopic evaluation showed a unilocular cyst lined by gastric type mucinous epithelium.", + "No papillary projection or configuration was seen.", + "Immunohistochemical stains showed the cyst wall lining to be diffusely positive for MUC5AC.", + "The mucinous lining was negative for MUC1 and MUC2.", + "The histological features were consistent with a simple mucinous cyst.", + "No dysplasia or carcinoma was seen.", + "There was focal thickening in the cyst wall with intraluminal nodular lesion characterized by amorphous eosinophilic congophilic material consistent with amyloid.", + "The amyloid deposits showed characteristic apple green birefringence on polarizing microscopy.", + "The amyloid deposits showed red fluorescence on fluorescent microscopy using Texas Red filter.", + "This focus correlated with the mural nodule seen on EUS.", + "LMD-LC–MS confirmed the amyloid to be lactoferrin type.", + "An immunostain for lactoferrin was positive in the amyloid deposits.", + "The background pancreas showed mild chronic pancreatitis.", + "No amyloid deposition was noted in the islets of Langerhans, interstitium, or blood vessels of the pancreas.", + "Her post-operative course was uneventful apart from a mild wound seroma.", + "She has since been seen multiple times in clinic following surgery.", + "She has recovered well." + ], + "summary": "We report a case of localized amyloidosis presenting as a mural nodule in a 1.6 cm cyst located in the head of pancreas, which led to pancreatoduodenectomy in a 69 year old woman. Histological evaluation revealed a simple mucinous cyst with localized lactoferrin amyloid deposition corresponding to the mural nodule identified on imaging.", + "summary_subclaims": [ + "The patient was a 69 year old woman.", + "The patient had a 1.6 cm cyst in the head of pancreas.", + "The cyst contained a mural nodule.", + "The mural nodule was identified on imaging.", + "The patient underwent pancreatoduodenectomy.", + "Histological evaluation revealed a simple mucinous cyst.", + "Localized lactoferrin amyloid deposition was found corresponding to the mural nodule." + ] + }, + { + "id": "multiclinsum_test_1352_en.txt", + "fulltext": "A 59-year-old woman was diagnosed with IgG kappa MM in May 2002, when she presented with Durie-Salmon stage III A disease with lytic destruction of the pelvis. Fluorescence in situ hybridization (FISH) performed on a bone marrow aspirate in 2006 did not reveal any high-risk cytogenetic abnormalities. Induction therapy with vincristine/doxo-rubicin/dexamethasone was followed by double autologous stem cell transplantation after conditioning with high-dose melphalan (200 mg/m2), resulting in a PR that lasted for 2 years. At first relapse, 4 cycles of bortezomib and subsequent bortezomib maintenance were administered and led to a PR for further 3 years. Third-line treatment with lenalidomide, bendamustine and dexamethasone produced only a short-lived response. Therapeutic attempts with the Hsp-90 inhibitor AUY-922 (phase I-Ib/II study) and bortezomib/dexa-methasone resulted in disease progression. Salvage treatment using multidrug combinations of two novel agents (bortezomib plus lenalidomide), alkylating agents (cyclophosphamide or melphalan) and dexamethasone also failed to induce a durable response. With high-grade plasma cell infiltration of the bone marrow , increasingly severe pancytopenia developed, causing chronic fatigue and impaired quality of life and eventually led to treatment discontinuation.\nIn August 2010, at the age of 68 and 8 years after primary diagnosis , we started treatment with pomalidomide (4 mg days 1–21 of a 28-day cycle) and low-dose dexamethasone (40 mg weekly) in combination with doxorubicin (4 mg days 1–4 by continuous infusion). Due to grade 3 thrombocytopenia, the pomalidomide dose was reduced to 2 mg from cycle 2 onwards, resulting in improved tolerability, serological PR and hematological improvement. However, myeloma therapy had to be stopped after six cycles due to the reactivation of a hepatitis B virus (HBV) infection (11.7 × 106 copies/ml), which the patient supposedly acquired in 1945 and which had never emerged during therapy before. Antiviral treatment with entecavir was initiated, which led to a sufficient drop in viral load (9.7 × 102 copies/ml).\nFive months after the interruption of antimyeloma treatment, the patient suffered from serological disease progression and a pathological humeral fracture requiring surgical treatment . To prevent further disease progression, one more cycle of pomalidomide/doxorubicin/dexamethasone was administered. For the subsequent cycles, doxorubicin was replaced by bendamustine (40 mg/m2 days 1–2) in light of the published data reporting an increased risk of HBV reactivation in patients receiving anthracyclines. However, two cycles of the new combination regimen resulted in transfusion-dependent anemia and grade 3 neutropenia, and only stable disease was observed.\nSince the patient was not eligible for treatment within one of the active clinical trials at our institution, individualized therapy was initiated, whereby pomalidomide (2 mg on days 1–21 of a 28-day cycle) was combined with bortezomib (1.3 mg/m2 day 1, 4), cyclophosphamide (250 mg days 1–3) and dexamethasone (10 mg days 1–3, weekly thereafter). As ninth-line therapy, this individualized combination regimen inhibited the progression of the bone lesions, and the patient continued to experience a good quality of life. When the symptoms of sensory polyneuropathy worsened after 18 cycles, bortezomib was reduced to 1.0 mg/m2 and the cycle length was extended to 43 days. Neuropathy improved gradually; however, we observed a steady rise in serologic disease activity. For the subsequent cycles, the pomalidomide dose was increased to 3 mg days 1–21 and the cycles were repeated on day 29, resulting in sustained PR. Due to an extended treatment-free interval after 34 cycles of pomalidomide + VCD (bortezomib/cyclophosphamide/dexamethasone), we observed an increase of serologic markers. More than 12 years after primary diagnosis and 4 years and 4 months after the first treatment with pomalidomide, regrettably, our patient succumbed to a fulminant pneumogenic septicemia in grade 1 neutropenia.", + "fulltext_subclaims": [ + "The patient was diagnosed with IgG kappa MM in May 2002.", + "At diagnosis, she had Durie-Salmon stage III A disease.", + "She had lytic destruction of the pelvis.", + "FISH performed in 2006 did not reveal any high-risk cytogenetic abnormalities.", + "Induction therapy was with vincristine/doxorubicin/dexamethasone.", + "She received double autologous stem cell transplantation after conditioning with high-dose melphalan (200 mg/m2).", + "The double autologous stem cell transplantation resulted in a partial response.", + "The partial response lasted for 2 years.", + "At first relapse, 4 cycles of bortezomib were administered.", + "Bortezomib maintenance was administered.", + "Bortezomib maintenance led to a partial response for further 3 years.", + "Third-line treatment was with lenalidomide, bendamustine and dexamethasone.", + "The third-line treatment produced only a short-lived response.", + "Therapeutic attempts with AUY-922 and bortezomib/dexamethasone resulted in disease progression.", + "Salvage treatment with multidrug combinations failed to induce a durable response.", + "High-grade plasma cell infiltration of the bone marrow was present.", + "Pancytopenia developed.", + "Pancytopenia caused chronic fatigue.", + "Pancytopenia caused impaired quality of life.", + "Treatment was discontinued.", + "In August 2010, treatment with pomalidomide (4 mg days 1–21 of a 28-day cycle) was started.", + "Low-dose dexamethasone (40 mg weekly) was used in combination.", + "Doxorubicin (4 mg days 1–4 by continuous infusion) was used in combination.", + "The pomalidomide dose was reduced to 2 mg from cycle 2 onwards due to grade 3 thrombocytopenia.", + "The reduced pomalidomide dose resulted in improved tolerability.", + "The reduced pomalidomide dose resulted in a serological partial response.", + "The reduced pomalidomide dose resulted in hematological improvement.", + "Myeloma therapy was stopped after six cycles due to reactivation of HBV infection.", + "HBV viral load was 11.7 × 106 copies/ml.", + "Antiviral treatment with entecavir was initiated.", + "Entecavir led to a sufficient drop in viral load.", + "HBV viral load was 9.7 × 102 copies/ml after entecavir.", + "Five months after treatment interruption, the patient suffered from serological disease progression.", + "A pathological humeral fracture occurred.", + "The humeral fracture required surgical treatment.", + "One more cycle of pomalidomide/doxorubicin/dexamethasone was administered.", + "Doxorubicin was replaced by bendamustine in subsequent cycles.", + "Two cycles of the new combination regimen resulted in transfusion-dependent anemia.", + "Two cycles of the new combination regimen resulted in grade 3 neutropenia.", + "Only stable disease was observed.", + "The patient was not eligible for treatment within active clinical trials.", + "Individualized therapy was initiated.", + "Pomalidomide (2 mg on days 1–21 of a 28-day cycle) was combined with bortezomib, cyclophosphamide and dexamethasone.", + "The individualized combination regimen inhibited the progression of bone lesions.", + "The patient continued to experience a good quality of life.", + "Bortezomib was reduced to 1.0 mg/m2 after 18 cycles due to worsening sensory polyneuropathy.", + "The cycle length was extended to 43 days.", + "Neuropathy improved gradually.", + "A steady rise in serologic disease activity was observed.", + "The pomalidomide dose was increased to 3 mg days 1–21.", + "Cycles were repeated on day 29.", + "Sustained partial response was achieved.", + "An extended treatment-free interval after 34 cycles of pomalidomide + VCD was observed.", + "Serologic markers increased.", + "The patient succumbed to fulminant pneumogenic septicemia.", + "The patient had grade 1 neutropenia at the time of death.", + "The patient was 68 years old at the start of pomalidomide treatment.", + "The patient was 8 years after primary diagnosis at the start of pomalidomide treatment.", + "The patient was 4 years and 4 months after the first treatment with pomalidomide at the time of death.", + "The patient was more than 12 years after primary diagnosis at the time of death." + ], + "summary": "We present the case of a 68-year-old woman with refractory MM who received pomalidomide in combination with various drugs including anthracyclines, alkylators and proteasome inhibitors. Initially, major hematological toxicities and infectious complications including a hepatitis B virus reactivation were encountered. With careful dose adjustments and selection of combination partners, pomalidomide treatment was maintained for over 4 years and led to a sustained partial remission. In particular, the well-tolerated regimen of bortezomib, cyclophosphamide and dexamethasone together with pomalidomide was administered for >30 cycles.", + "summary_subclaims": [ + "The patient was a 68-year-old woman.", + "The patient had refractory multiple myeloma.", + "The patient received pomalidomide in combination with various drugs.", + "The combination drugs included anthracyclines, alkylators, and proteasome inhibitors.", + "Initially, major hematological toxicities were encountered.", + "Infectious complications were encountered.", + "A hepatitis B virus reactivation was encountered.", + "Pomalidomide treatment was maintained for over 4 years.", + "Pomalidomide treatment led to a sustained partial remission.", + "The regimen of bortezomib, cyclophosphamide, and dexamethasone together with pomalidomide was well-tolerated.", + "The regimen was administered for >30 cycles." + ] + }, + { + "id": "multiclinsum_test_1580_en.txt", + "fulltext": "A 63-year-old female patient was admitted to the Third Affiliated Hospital of Guangzhou Medical University for abdominal pain, anal irritation, and repeated hematochezia. Her 31-year-old son was previously diagnosed with SRUS and underwent an inpatient examination.\nHer symptoms started 1 year before the presentation of abdominal pain, anal irritation, and repeated hematochezia. Additionally, her 31-year-old son started to present with repeated diarrhea and intermittent hematochezia at the age of 26. He suffered from chronic diarrhea of up to 30 times a day, with the worst demonstrating fecal incontinence. He was subsequently diagnosed with SRUS 3 years ago and underwent surgical removal. The surgical pathology was consistent with the pathological features of SRUS . Hematochezia disappeared postoperatively, but his diarrhea remained. Chronic diarrhea causes his anxiety because his symptoms worsen as his mood changed.\nThe patients were healthy before the SRUS incidence.\nThe patient has two sons and one daughter. Notably, one of her sons was diagnosed with SRUS before her diagnosis and underwent partial rectal resection. The other son was healthy. Additionally, she and her son with SRUS like to eat mixed and coarse grains, and they have high-fiber eating habits and a sedentary lifestyle. Moreover, they are accustomed to squatting for a long time to defecate. Furthermore, they were healthy before the SRUS incidence, but are prone to anxious behaviors in life.\nA physical examination upon admission revealed no obvious abnormality in both patients.\nLaboratory tests of the female patient revealed high triglyceride (2.11 mmol/L), while others were all within normal ranges. Further, Epstein-Barr virus, and cytomegalovirus were negative. Blood routine, coagulation function and autoimmune tests were within normal ranges. Additionally, laboratory tests of the male patient upon admission revealed no obvious abnormality.\nHer total digestive tract endoscopy results revealed a rectal solitary ulcer , the indicarmine dyeing demonstrated a clear boundary , and pathological results indicated the fibrous tissue hyperplasia in the lamina propria layer as well as glands destruction . Ultrasonic endoscopy revealed clearly demarcated mucosal layers, missing ulcerative mucosa and submucosa layers, and intact and thickened muscularis propria . Moreover, the intestinal computed tomography enhancement revealed segmental rectal wall thickening . The anorectal function test demonstrated a low resting pressure of the anal canal and normal contractile response and anorectal inhibition reflex but with increased anorectal sensitivity. Further, a colonoscopy of the male patient showed that the mucosa of his rectal anastomosis was smooth without any erosion or ulcer .\nWhereas their complicate family history and next-generation sequencing of heritage whole exome sequencing was then conducted with their consent. The results exhibited a CHEK2 gene (c.1111C>T, p.His371Tyr) missense mutation in the patient and her son with SRUS, but not in the other son and the daughter. The CHEK2 p.H371Y mutation was reported as a kind of pathologic mutation. Then we conduct the immunohistochemical staining (IHC) to analyze the expression and function of CHEK2 (Antibody: CHEK2, CST#3440, 1:1600; p-CHEK2, CST#82263, 1:500; CDC25A, CST#3652, 1:100; p-P53, CST#9287, 1:100), which revealed a normal CHEK2 protein level but an impaired downstream gene protein level. As shown in Figure , CHEK2 protein levels and autophosphorylation CHEK2 protein levels showed no significant difference among the healthy control, inflammatory bowel diseases, rectal cancer and SRUS groups (including familial and sporadic cases). In contrast, the downstream gene of CHEK2, such as CDC25A and p-P53 (Ser 20), exhibit differential expression among these groups. CDC25A and p-p53 protein expression levels were the highest and the lowest in the SRUS group, while the differences between the SRUS and rectal cancer groups do not reach significance.\nThe SRUS groups contain familial patients in our case and non-familial cases (sporadic cases). The IHC results revealed that the CHEK2 mutation did not affect the expression of CHEK2 protein whether in familial SRUS cases or sporadic SRUS cases, but it would affect CHEK2 functions to different degrees. CDC25A expression level variations are more significant in familial SRUS cases, while p-p53 expression level changes are more pronounced in sporadic SRUS cases.", + "fulltext_subclaims": [ + "A 63-year-old female patient was admitted to the Third Affiliated Hospital of Guangzhou Medical University for abdominal pain, anal irritation, and repeated hematochezia.", + "Her 31-year-old son was previously diagnosed with SRUS and underwent an inpatient examination.", + "Her symptoms started 1 year before the presentation of abdominal pain, anal irritation, and repeated hematochezia.", + "Her 31-year-old son started to present with repeated diarrhea and intermittent hematochezia at the age of 26.", + "He suffered from chronic diarrhea of up to 30 times a day, with the worst demonstrating fecal incontinence.", + "He was subsequently diagnosed with SRUS 3 years ago and underwent surgical removal.", + "The surgical pathology was consistent with the pathological features of SRUS.", + "Hematochezia disappeared postoperatively, but his diarrhea remained.", + "Chronic diarrhea causes his anxiety because his symptoms worsen as his mood changed.", + "The patients were healthy before the SRUS incidence.", + "The patient has two sons and one daughter.", + "One of her sons was diagnosed with SRUS before her diagnosis and underwent partial rectal resection.", + "The other son was healthy.", + "She and her son with SRUS like to eat mixed and coarse grains.", + "They have high-fiber eating habits and a sedentary lifestyle.", + "They are accustomed to squatting for a long time to defecate.", + "They were healthy before the SRUS incidence.", + "A physical examination upon admission revealed no obvious abnormality in both patients.", + "Laboratory tests of the female patient revealed high triglyceride (2.11 mmol/L), while others were all within normal ranges.", + "Epstein-Barr virus and cytomegalovirus were negative.", + "Blood routine, coagulation function, and autoimmune tests were within normal ranges.", + "Laboratory tests of the male patient upon admission revealed no obvious abnormality.", + "Her total digestive tract endoscopy results revealed a rectal solitary ulcer.", + "The indigo carmine dyeing demonstrated a clear boundary.", + "Pathological results indicated fibrous tissue hyperplasia in the lamina propria layer as well as glands destruction.", + "Ultrasonic endoscopy revealed clearly demarcated mucosal layers, missing ulcerative mucosa and submucosa layers, and intact and thickened muscularis propria.", + "Intestinal computed tomography enhancement revealed segmental rectal wall thickening.", + "The anorectal function test demonstrated a low resting pressure of the anal canal and normal contractile response and anorectal inhibition reflex but with increased anorectal sensitivity.", + "A colonoscopy of the male patient showed that the mucosa of his rectal anastomosis was smooth without any erosion or ulcer.", + "Next-generation sequencing of heritage whole exome sequencing was conducted with their consent.", + "The results exhibited a CHEK2 gene (c.1111C>T, p.His371Tyr) missense mutation in the patient and her son with SRUS, but not in the other son and the daughter.", + "The CHEK2 p.H371Y mutation was reported as a kind of pathologic mutation.", + "Immunohistochemical staining (IHC) was conducted to analyze the expression and function of CHEK2.", + "The IHC revealed a normal CHEK2 protein level but an impaired downstream gene protein level.", + "CHEK2 protein levels and autophosphorylation CHEK2 protein levels showed no significant difference among the healthy control, inflammatory bowel diseases, rectal cancer, and SRUS groups.", + "The downstream gene of CHEK2, such as CDC25A and p-P53 (Ser 20), exhibit differential expression among these groups.", + "CDC25A and p-p53 protein expression levels were the highest and the lowest in the SRUS group.", + "The differences between the SRUS and rectal cancer groups do not reach significance.", + "The SRUS groups contain familial patients in our case and non-familial cases (sporadic cases).", + "The IHC results revealed that the CHEK2 mutation did not affect the expression of CHEK2 protein whether in familial SRUS cases or sporadic SRUS cases.", + "CDC25A expression level variations are more significant in familial SRUS cases.", + "p-p53 expression level changes are more pronounced in sporadic SRUS cases." + ], + "summary": "Here, we report the first case of SRUS in a mother-son relationship. Gene sequencing was conducted on the whole family, which revealed an inherited CHEK2 p.H371Y mutation. The experiment preliminarily revealed that the CHEK2 mutation did not affect the expression of CHEK2 protein, but affected the function of CHEK2, resulting in the expression level changes of downstream genes such as CDC25A.", + "summary_subclaims": [ + "This is the first case of SRUS reported in a mother-son relationship.", + "Gene sequencing was conducted on the whole family.", + "An inherited CHEK2 p.H371Y mutation was revealed.", + "The experiment preliminarily revealed that the CHEK2 mutation did not affect the expression of CHEK2 protein.", + "The CHEK2 mutation affected the function of CHEK2.", + "The CHEK2 mutation resulted in the expression level changes of downstream genes such as CDC25A." + ] + }, + { + "id": "multiclinsum_test_230_en.txt", + "fulltext": "A 37 year old female presented to her primary care physician with nonspecific abdominal pain. She underwent CT imaging that revealed bilateral ovarian masses and ascites. Preoperative CA125 was the only tumor marker examined and it was within normal limits. A presumptive diagnosis of ovarian cancer was made and she underwent exploratory laparotomy which revealed macroscopic peritoneal metastases to ovaries, omentum and pelvic peritoneum. At that time total abdominal hysterectomy, bilateral salpingoopherectomy, pelvic lymph node sampling, partial omentectomy, appendectomy and evacuation of mucinous ascites was performed. Final pathology revealed low grade mucinous adenocarcinoma in all specimens, arising from an appendiceal primary. The patient received no additional therapy and was followed clinically. She developed recurrent abdominal pain approximately 2 years later. Computed tomography (CT) scan revealed progressive nodularity in the mesentery and peritoneal surfaces consistent with recurrent disease. This was further evaluated with a laparoscopy, which revealed mucinous tumor implants along the anterior abdominal wall, right retroperitoneum, diaphragm, and remaining omentum . At this time, the patient was referred to the University of Cincinnati for consideration of cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion. The patient's past medical history was significant only for a seizure disorder which was managed by anticonvulsant medication and an implanted vagus nerve stimulator. Preoperative CA19-9 was elevated at 59, while CEA and CA-125 were normal. The patient was felt to be an appropriate candidate and underwent exploration. At surgery, extensive disease was noted over the peritoneal surfaces. A complete cytoreduction was achieved requiring, right colectomy, splenectomy, cholecystectomy, omentectomy, and perionectomies of the diaphragms, anterior abdominal wall, and pelvis. Tumor nodules were excised from the small bowel and large bowel mesentery. The cytoreductive portion of the operation was completed in approximately 210 minutes. Per our current practice protocol, a 90 minute perfusion was performed using an inflow temperature of 44°C, with peritoneal surface temperatures averaging 40.5–41.5°C. Intraperitoneal temperatures were measured via four temperature probes, one within the liver parenchyma, and three within separate quadrants of the peritoneum. Core temperature was recorded via the bladder and esophageal temperature probes. Per our standard protocol, the carrier solution was peritoneal dialysis fluid (2.5%). The patient's maximum recorded core body temperature during the procedure was 38.7°C and the maximum recorded liver temperature was 38.8°C. Mitomycin C was delivered using a total dose of 10 mg/L perfusate, delivered in divided doses of 7 mg/L at initiation and redosed after 45 minutes at 3 mg/L. A total dose of 45 mg was delivered in this patient. During the operation, the patient had no significant electrolyte abnormalities aside from the expected glucose elevation seen during the perfusion period. The maximum serum glucose was 355 mg/dL and the lowest serum sodium was 135. The operation was generally uneventful; no blood transfusions were required and the patient was transferred to the ICU in stable condition. Postoperatively, all serum electrolytes were normal and albumin was 3.4 mg/dl compared with 4.3 mg/dl, preoperatively. The patient was easily arousable and followed commands appropriately. However, approximately 4 hrs later, the patient complained of headache and right eye pain. Her headache was treated with analgesics, however 3 hours later, she was found to be tachypenic, bradycardic, and hypotensive, and was unresponsive with fixed, dilated pupils. She was emergently intubated and resuscitated. After approximately 15 minutes, she regained consciousness, and responded appropriately to commands. Her pupils returned to 3 mm and because reactive. Neurology was consulted and she was loaded with Dilantin due to her history of seizure disorder. An urgent CT scan was ordered. On route to the CT scanner, she once again became bradycardic and hypotensive with fixed, dilated pupils. The CT scan revealed diffuse cerebral edema . ICP monitoring revealed pressures of 70–90 mmHg. Mannitol was used in an attempt to lower intracranial pressure without success. EEG was consistent with diffuse brain dysfunction. A brain death protocol revealed that she had suffered brain death and care was subsequently withdrawn. At autopsy, diffuse cerebral edema with tonsillar herniation was noted . No pathologic findings were present to indicate the cause of the cerebral edema. The final pathology on all resected specimens reconfirmed the diagnosis of mucinous adenocarcinoma .", + "fulltext_subclaims": [ + "The patient was a 37 year old female.", + "She presented with nonspecific abdominal pain.", + "CT imaging revealed bilateral ovarian masses.", + "CT imaging revealed ascites.", + "Preoperative CA125 was the only tumor marker examined.", + "Preoperative CA125 was within normal limits.", + "A presumptive diagnosis of ovarian cancer was made.", + "She underwent exploratory laparotomy.", + "Exploratory laparotomy revealed macroscopic peritoneal metastases to ovaries.", + "Exploratory laparotomy revealed macroscopic peritoneal metastases to omentum.", + "Exploratory laparotomy revealed macroscopic peritoneal metastases to pelvic peritoneum.", + "Total abdominal hysterectomy was performed.", + "Bilateral salpingoopherectomy was performed.", + "Pelvic lymph node sampling was performed.", + "Partial omentectomy was performed.", + "Appendectomy was performed.", + "Evacuation of mucinous ascites was performed.", + "Final pathology revealed low grade mucinous adenocarcinoma in all specimens.", + "The tumor was noted to arise from an appendiceal primary.", + "The patient received no additional therapy.", + "She was followed clinically.", + "She developed recurrent abdominal pain approximately 2 years later.", + "CT scan revealed progressive nodularity in the mesentery.", + "CT scan revealed progressive nodularity in the peritoneal surfaces.", + "CT findings were consistent with recurrent disease.", + "Laparoscopy revealed mucinous tumor implants along the anterior abdominal wall.", + "Laparoscopy revealed mucinous tumor implants along the right retroperitoneum.", + "Laparoscopy revealed mucinous tumor implants along the diaphragm.", + "Laparoscopy revealed mucinous tumor implants along the remaining omentum.", + "The patient was referred to the University of Cincinnati for consideration of cytoreductive surgery.", + "The patient was referred to the University of Cincinnati for consideration of intraperitoneal hyperthermic chemoperfusion.", + "Preoperative CA19-9 was elevated at 59.", + "Preoperative CEA was normal.", + "Preoperative CA-125 was normal.", + "The patient was felt to be an appropriate candidate.", + "Exploration was performed.", + "At surgery, extensive disease was noted over the peritoneal surfaces.", + "A complete cytoreduction was achieved.", + "Right colectomy was performed.", + "Splenectomy was performed.", + "Cholecystectomy was performed.", + "Omentectomy was performed.", + "Perionectomies of the diaphragms were performed.", + "Perionectomies of the anterior abdominal wall were performed.", + "Perionectomies of the pelvis were performed.", + "Tumor nodules were excised from the small bowel mesentery.", + "Tumor nodules were excised from the large bowel mesentery.", + "The cytoreductive portion of the operation was completed in approximately 210 minutes.", + "A 90 minute perfusion was performed.", + "The inflow temperature was 44°C.", + "Peritoneal surface temperatures averaged 40.5–41.5°C.", + "Intraperitoneal temperatures were measured via four temperature probes.", + "One temperature probe was within the liver parenchyma.", + "Three temperature probes were within separate quadrants of the peritoneum.", + "Core temperature was recorded via the bladder and esophageal temperature probes.", + "The carrier solution was peritoneal dialysis fluid (2.5%).", + "The patient's maximum recorded core body temperature during the procedure was 38.7°C.", + "The patient's maximum recorded liver temperature was 38.8°C.", + "Mitomycin C was delivered using a total dose of 10 mg/L perfusate.", + "Mitomycin C was delivered in divided doses of 7 mg/L at initiation.", + "Mitomycin C was redosed after 45 minutes at 3 mg/L.", + "A total dose of 45 mg Mitomycin C was delivered.", + "The patient had no significant electrolyte abnormalities aside from the expected glucose elevation.", + "The maximum serum glucose was 355 mg/dL.", + "The lowest serum sodium was 135.", + "The operation was generally uneventful.", + "No blood transfusions were required.", + "The patient was transferred to the ICU in stable condition.", + "Postoperatively, all serum electrolytes were normal.", + "Postoperative albumin was 3.4 mg/dl.", + "Preoperative albumin was 4.3 mg/dl.", + "Approximately 4 hrs postoperatively, the patient complained of headache.", + "Approximately 4 hrs postoperatively, the patient complained of right eye pain.", + "The headache was treated with analgesics.", + "Three hours after the headache, the patient was found to be tachypenic.", + "Three hours after the headache, the patient was found to be bradycardic.", + "Three hours after the headache, the patient was found to be hypotensive.", + "The patient was unresponsive with fixed, dilated pupils.", + "The patient was emergently intubated.", + "The patient was resuscitated.", + "After approximately 15 minutes, the patient regained consciousness.", + "After approximately 15 minutes, the patient responded appropriately to commands.", + "The patient's pupils returned to 3 mm.", + "The patient's pupils were reactive.", + "Neurology was consulted.", + "The patient was loaded with Dilantin.", + "An urgent CT scan was ordered.", + "On route to the CT scanner, the patient once again became bradycardic.", + "On route to the CT scanner, the patient once again became hypotensive.", + "On route to the CT scanner, the patient had fixed, dilated pupils.", + "The CT scan revealed diffuse cerebral edema.", + "ICP monitoring revealed pressures of 70–90 mmHg.", + "Mannitol was used in an attempt to lower intracranial pressure.", + "Mannitol was unsuccessful in lowering intracranial pressure.", + "EEG was consistent with diffuse brain dysfunction.", + "A brain death protocol was performed.", + "The patient was found to have suffered brain death.", + "Care was subsequently withdrawn.", + "At autopsy, diffuse cerebral edema with tonsillar herniation was noted.", + "No pathologic findings were present to indicate the cause of the cerebral edema.", + "Final pathology on all resected specimens reconfirmed the diagnosis of mucinous adenocarcinoma." + ], + "summary": "A case of fatal postoperative cerebral edema is presented in a patient with an underlying seizure disorder and recurrent mucinous adenocarcinoma of the appendix. The patient was treated with cytoreductive surgery and intraoperative intraperitoneal hyperthermic chemoperfusion. The details and implications of this complication are discussed.", + "summary_subclaims": [ + "A case of fatal postoperative cerebral edema is presented.", + "The patient had an underlying seizure disorder.", + "The patient had recurrent mucinous adenocarcinoma of the appendix.", + "The patient was treated with cytoreductive surgery.", + "The patient received intraoperative intraperitoneal hyperthermic chemoperfusion.", + "The details and implications of this complication are discussed." + ] + }, + { + "id": "multiclinsum_test_1437_en.txt", + "fulltext": "A 50-year-old male patient, who is self-employed, presented to our hospital in January 2022 with a chief complaint of a persistent cough for the past 2 months, without significant shortness of breath, palpitations, or fever. His medical history revealed a previous hepatitis B infection, which resulted in hepatic failure 10 years ago. Additionally, he was diagnosed with HIV infection. However, he ceased taking antiviral treatment with the medications provided free of charge by the Chinese government for a period of three years. During this hospital visit, his CD4 + T-cell count was found to be 26/μL (normal range: 500–1612/μL), HIV-1 RNA was 1.1 × 105 copies/ml, and HBV-DNA was negative. Chest computed tomography (CT) scan revealed nodular and patchy lung lesions . The BALF shows positive acid-fast staining. Further assessment of the BALF using XpertMTB/RIF PCR revealed resistance to rifampicin, and the tuberculosis drug susceptibility test of the BALF (liquid culture, medium MGIT 960) indicated resistance to rifampicin, isoniazid, and streptomycin. Considering the World Health Organization (WHO) guidelines for drug-resistant tuberculosis, the patient’s drug susceptibility results, and the co-infection of HIV and HBV, an individualized treatment plan was tailored for him. The treatment plan included BIC/TAF/FTC (50 mg/25 mg/200 mg per day) for HBV and HIV antiviral therapy, as well as linezolid (0.6 g/day), cycloserine (0.5 g/day), moxifloxacin (0.4 g/day), pyrazinamide (1.5 g/day), and ethambutol (0.75 g/day) for anti-tuberculosis treatment, along with supportive care.\nUnfortunately, after 3 months of follow-up, the patient discontinued all medications due to inaccessibility of the drugs. He returned to our hospital (Nov 12, 2022, day 0) after discontinuing medication for six months, with a complaint of poor appetite for the past 10 days. Elevated liver enzymes were observed, with an alanine aminotransferase level of 295 IU/L (normal range: 0–40 IU/L) and a total bilirubin(TBIL) level of 1.8 mg/dL (normal range: 0–1 mg/dL). His HBV viral load increased to 5.5 × 109 copies/ml. Considering the liver impairment, elevated HBV-DNA and the incomplete anti-tuberculosis treatment regimen , we discontinued pyrazinamide and initiated treatment with linezolid, cycloserine, levofloxacin, and ethambutol for anti-tuberculosis therapy, along with BIC/TAF/FTC for HIV and HBV antiviral treatment. Additionally, enhanced liver protection and supportive management were provided, involving hepatoprotective effects of medications such as glutathione, magnesium isoglycyrrhizinate, and bicyclol. However, the patient’s TBIL levels continued to rise progressively, reaching 4.4 mg/dL on day 10 . Suspecting drug-related factors, we discontinued all anti-tuberculosis medications while maintaining BIC/TAF/FTC for antiviral therapy, the patient’s TBIL levels continued to rise persistently. We ruled out other viral hepatitis and found no significant evidence of obstructive lesions on magnetic resonance cholangiopancreatography. Starting from the day 19, due to the patient’s elevated TBIL levels of 12.5 mg/dL, a decrease in prothrombin activity (PTA) to 52% , and the emergence of evident symptoms such as abdominal distension and poor appetite, we initiated aggressive treatment methods. Unfortunately, on day 38, his hemoglobin level dropped to 65 g/L (normal range: 120–170 g/L, Fig. A), and his platelet count decreased to 23 × 109/L (normal range: 125–300 × 109/L, Fig. C). Based on a score of 7 on the Naranjo Scale, it was highly suspected that “Linezolid” was the cause of these hematological abnormalities. Therefore, we had to discontinue Linezolid for the anti-tuberculosis treatment. Subsequently, on day 50, the patient developed recurrent fever, a follow-up chest CT scan revealed enlarged nodules in the lungs . The patient also reported mild dizziness and a worsening cough. On day 61, the previous blood culture results reported the growth of Cryptococcus. A lumbar puncture was performed on the same day, and the cerebrospinal fluid (CSF) opening pressure was measured at 130 mmH2O. India ink staining of the CSF showed typical encapsulated yeast cells suggestive of Cryptococcus. Other CSF results indicated mild leukocytosis and mildly elevated protein levels, while chloride and glucose levels were within normal limits. Subsequently, the patient received a fungal treatment regimen consisting of liposomal amphotericin B (3 mg/kg·d−1) in combination with fluconazole(600 mg/d). After 5 days of antifungal therapy, the patient’s fever symptoms were well controlled. Despite experiencing bone marrow suppression, including thrombocytopenia and worsening anemia, during this period, proactive symptom management, such as the use of erythropoietin, granulocyte colony-stimulating factor, and thrombopoietin, along with high-calorie dietary management, even reducing the dosage of liposomal amphotericin B to 2 mg/kg/day for 10 days at the peak of severity, successfully controlled the bone marrow suppression. However, within the following week, the patient experienced fever again, accompanied by a worsened cough, increased sputum production, and dyspnea. Nevertheless, the bilirubin levels did not show a significant increase. On day 78 the patient’s lung CT revealed patchy infiltrates and an increased amount of pleural effusion . The CD4 + T-cell count was 89/μL (normal range: 500–700/μL), indicating a significant improvement in immune function compared to the previous stage, and C-reactive protein was significantly elevated, reflecting the inflammatory state, other inflammatory markers such as IL-6 and γ-IFN were also significantly elevated. On day 84, Considering the possibility of IRIS, the patient began taking methylprednisolone 30 mg once a day as part of an effort to control his excessive inflammation. Following the administration of methylprednisolone, the man experienced an immediate improvement in his fever. Additionally, symptoms such as cough, sputum production, dyspnea, and poor appetite gradually subsided over time. A follow-up lung CT showed significant improvement, indicating a positive response to the treatment. After 28 days of treatment with liposomal amphotericin B in combination with fluconazole, liposomal amphotericin B was discontinued, and the patient continued with fluconazole to consolidate the antifungal therapy for Cryptococcus. Considering the patient’s ongoing immunodeficiency, the dosage of methylprednisolone was gradually reduced by 4 mg every week. After improvement in liver function, the patient’s anti-tuberculosis treatment regimen was adjusted to include bedaquiline, contezolid, cycloserine, moxifloxacin, and ethambutol. The patient’s condition was well controlled, and a follow-up lung CT on day 117 indicated a significant improvement in lung lesions .", + "fulltext_subclaims": [ + "The patient is a 50-year-old male.", + "The patient presented in January 2022.", + "The patient had a persistent cough for the past 2 months.", + "The patient did not have significant shortness of breath.", + "The patient did not have palpitations.", + "The patient did not have fever.", + "The patient had a previous hepatitis B infection.", + "The previous hepatitis B infection resulted in hepatic failure 10 years ago.", + "The patient was diagnosed with HIV infection.", + "The patient stopped taking antiviral treatment provided free of charge by the Chinese government for three years.", + "The patient’s CD4 + T-cell count was 26/μL.", + "The normal range for CD4 + T-cell count is 500–1612/μL.", + "HIV-1 RNA was 1.1 × 105 copies/ml.", + "HBV-DNA was negative.", + "Chest CT scan revealed nodular and patchy lung lesions.", + "BALF showed positive acid-fast staining.", + "XpertMTB/RIF PCR of BALF revealed resistance to rifampicin.", + "The tuberculosis drug susceptibility test of BALF indicated resistance to rifampicin.", + "The tuberculosis drug susceptibility test of BALF indicated resistance to isoniazid.", + "The tuberculosis drug susceptibility test of BALF indicated resistance to streptomycin.", + "An individualized treatment plan was tailored for the patient.", + "The treatment plan included BIC/TAF/FTC (50 mg/25 mg/200 mg per day).", + "The treatment plan included linezolid (0.6 g/day).", + "The treatment plan included cycloserine (0.5 g/day).", + "The treatment plan included moxifloxacin (0.4 g/day).", + "The treatment plan included pyrazinamide (1.5 g/day).", + "The treatment plan included ethambutol (0.75 g/day).", + "After 3 months of follow-up, the patient discontinued all medications.", + "The patient returned to the hospital on Nov 12, 2022.", + "The patient had poor appetite for the past 10 days.", + "Alanine aminotransferase level was 295 IU/L.", + "The normal range for alanine aminotransferase is 0–40 IU/L.", + "Total bilirubin level was 1.8 mg/dL.", + "The normal range for total bilirubin is 0–1 mg/dL.", + "HBV viral load increased to 5.5 × 109 copies/ml.", + "Pyrazinamide was discontinued.", + "Linezolid, cycloserine, levofloxacin, and ethambutol were initiated for anti-tuberculosis therapy.", + "BIC/TAF/FTC was continued for HIV and HBV antiviral treatment.", + "Enhanced liver protection was provided.", + "Medications for hepatoprotective effects included glutathione.", + "Medications for hepatoprotective effects included magnesium isoglycyrrhizinate.", + "Medications for hepatoprotective effects included bicyclol.", + "TBIL levels continued to rise progressively.", + "TBIL levels reached 4.4 mg/dL on day 10.", + "All anti-tuberculosis medications were discontinued.", + "BIC/TAF/FTC was maintained for antiviral therapy.", + "Other viral hepatitis was ruled out.", + "No significant evidence of obstructive lesions was found on magnetic resonance cholangiopancreatography.", + "On day 19, TBIL levels were 12.5 mg/dL.", + "On day 19, prothrombin activity was 52%.", + "On day 19, the patient had abdominal distension.", + "On day 19, the patient had poor appetite.", + "On day 38, hemoglobin level was 65 g/L.", + "The normal range for hemoglobin is 120–170 g/L.", + "On day 38, platelet count was 23 × 109/L.", + "The normal range for platelet count is 125–300 × 109/L.", + "A score of 7 on the Naranjo Scale was obtained.", + "It was highly suspected that “Linezolid” caused the hematological abnormalities.", + "Linezolid was discontinued.", + "On day 61, blood culture results reported the growth of Cryptococcus.", + "A lumbar puncture was performed on day 61.", + "CSF opening pressure was 130 mmH2O.", + "India ink staining of CSF showed typical encapsulated yeast cells.", + "CSF results indicated mild leukocytosis.", + "CSF results indicated mildly elevated protein levels.", + "CSF chloride levels were within normal limits.", + "CSF glucose levels were within normal limits.", + "The patient received liposomal amphotericin B (3 mg/kg·d−1).", + "The patient received fluconazole (600 mg/d).", + "After 5 days of antifungal therapy, fever symptoms were well controlled.", + "Bone marrow suppression included thrombocytopenia.", + "Bone marrow suppression included worsening anemia.", + "Erythropoietin was used.", + "Granulocyte colony-stimulating factor was used.", + "Thrombopoietin was used.", + "High-calorie dietary management was provided.", + "Liposomal amphotericin B was reduced to 2 mg/kg/day.", + "The patient experienced fever again.", + "The patient had a worsened cough.", + "The patient had increased sputum production.", + "The patient had dyspnea.", + "Bilirubin levels did not show a significant increase.", + "On day 78, lung CT revealed patchy infiltrates.", + "On day 78, lung CT showed increased pleural effusion.", + "CD4 + T-cell count was 89/μL.", + "The normal range for CD4 + T-cell count is 500–700/μL.", + "C-reactive protein was significantly elevated.", + "IL-6 was significantly elevated.", + "γ-IFN was significantly elevated.", + "On day 84, the patient began taking methylprednisolone 30 mg once a day.", + "Fever improved immediately after methylprednisolone.", + "Cough gradually subsided.", + "Sputum production gradually subsided.", + "Dyspnea gradually subsided.", + "Poor appetite gradually subsided.", + "A follow-up lung CT showed significant improvement.", + "Liposomal amphotericin B was discontinued after 28 days.", + "The patient continued with fluconazole.", + "Methylprednisolone dosage was gradually reduced by 4 mg every week.", + "After improvement in liver function, anti-tuberculosis treatment was adjusted.", + "The adjusted anti-tuberculosis regimen included bedaquiline.", + "The adjusted anti-tuberculosis regimen included contezolid.", + "The adjusted anti-tuberculosis regimen included cycloserine.", + "The adjusted anti-tuberculosis regimen included moxifloxacin.", + "The adjusted anti-tuberculosis regimen included ethambutol.", + "The patient’s condition was well controlled.", + "A follow-up lung CT on day 117 indicated significant improvement in lung lesions." + ], + "summary": "The 50-year-old male with a history of chronic hepatitis B and untreated human immunodeficiency virus (HIV) infection presented to the hospital with a mild cough and expectoration, revealing multi-drug resistant pulmonary tuberculosis (MDR-PTB), which was confirmed by XpertMTB/RIF PCR testing and tuberculosis culture of bronchoalveolar lavage fluid (BALF). The patient was treated with a regimen consisting of linezolid, moxifloxacin, cycloserine, pyrazinamide, and ethambutol for tuberculosis, as well as a combination of bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) for HBV and HIV viral suppression. After three months of treatment, the patient discontinued all medications, leading to hepatitis B virus reactivation and subsequent liver failure. During the subsequent treatment for AIDS, HBV, and drug-resistant tuberculosis, the patient developed disseminated cryptococcal disease. The patient's condition worsened during treatment with liposomal amphotericin B and fluconazole, which was ultimately attributed to IRIS. Fortunately, the patient achieved successful recovery after appropriate management.", + "summary_subclaims": [ + "The patient is a 50-year-old male.", + "The patient has a history of chronic hepatitis B.", + "The patient has untreated human immunodeficiency virus (HIV) infection.", + "The patient presented with a mild cough and expectoration.", + "The patient was diagnosed with multi-drug resistant pulmonary tuberculosis.", + "The diagnosis of multi-drug resistant pulmonary tuberculosis was confirmed by XpertMTB/RIF PCR testing.", + "The diagnosis of multi-drug resistant pulmonary tuberculosis was confirmed by tuberculosis culture of bronchoalveolar lavage fluid.", + "The patient was treated with linezolid.", + "The patient was treated with moxifloxacin.", + "The patient was treated with cycloserine.", + "The patient was treated with pyrazinamide.", + "The patient was treated with ethambutol.", + "The patient was treated with bictegravir/tenofovir alafenamide/emtricitabine.", + "After three months of treatment, the patient discontinued all medications.", + "Hepatitis B virus reactivation occurred after medication discontinuation.", + "Hepatitis B virus reactivation led to liver failure.", + "The patient developed disseminated cryptococcal disease.", + "The patient was treated with liposomal amphotericin B.", + "The patient was treated with fluconazole.", + "The patient's condition worsened during treatment with liposomal amphotericin B and fluconazole.", + "The patient's worsening condition was attributed to IRIS.", + "The patient achieved successful recovery after appropriate management." + ] + }, + { + "id": "multiclinsum_test_562_en.txt", + "fulltext": "This is the case of a 15-year-old Kenyan girl of Kikuyu descent who presented with a diffuse, painful, slight cheek swelling on the right side of her face. The pain and swelling consistently increased in size just before and during meals. The painful area was well defined and the pain confined with no radiation. Her medical and dental histories were unremarkable except for treatment for otitis media 3 months before her presentation.\nOn examination her chronologic age was commensurate with her physique. The right parotid area was tender with no obvious change in the skin color. Intraorally, she had unerupted 8 s, missing 12, and a peg lateral in place of 22. The intraoral soft tissue was normal in color, texture, and consistency except around the right Stensen’s duct opening, which was inflamed. A small amount of pus was expressed from the right duct when slight pressure was applied on the papilla.\nA diagnosis of acute suppurative sialadenitis was made and treatment executed in the form of copious fluid intake, amoxicillin and clavulanic acid (500 mg/12 5 mg) twice a day for 5 days, paracetamol 1000 mg three times a day for 5 days and povidone-iodine (Betadine) gargle for 7 days. The infection resolved completely until about a year later when she presented with signs and symptoms as those initially observed. A similar treatment regimen was prescribed and, after elimination of the infection, the patency of the right Stensen’s duct was checked by cannulation with no indication of obstruction.\nAbout 2 years following her initial submission she presented with a recurrence of the initial signs and symptoms. It was immediately decided to perform a magnetic resonance imaging (MRI) scan . This showed a homogenous well-defined right cheek lesion medial to the buccinator muscle and engulfing the ipsilateral Stensen’s duct. The clinical and radiographic features of the lesion were suggestive of a lipoma with the differential diagnosis of oral dermoid cyst, epidermoid cyst, and lymphoepithelial cysts considered. A decision was made to excise the lesion via an intraoral approach . The Stensen’s duct was cannulated for localization and protection during the surgery. Following excision of the lesion, histopathology diagnosis confirmed a lipoma of the right cheek area. Immediately following recovery from the surgery, our patient reported complete resolution of previously noted symptoms of pain, discomfort, and swelling that were related to mealtimes. Six months following surgery, our patient is symptom-free and continues to be monitored.", + "fulltext_subclaims": [ + "The patient is a 15-year-old Kenyan girl of Kikuyu descent.", + "She presented with a diffuse, painful, slight cheek swelling on the right side of her face.", + "The pain and swelling consistently increased in size just before and during meals.", + "The painful area was well defined and the pain confined with no radiation.", + "Her medical and dental histories were unremarkable except for treatment for otitis media 3 months before her presentation.", + "On examination, the right parotid area was tender with no obvious change in the skin color.", + "Intraorally, she had unerupted 8 s, missing 12, and a peg lateral in place of 22.", + "The intraoral soft tissue was normal in color, texture, and consistency except around the right Stensen’s duct opening, which was inflamed.", + "A small amount of pus was expressed from the right duct when slight pressure was applied on the papilla.", + "A diagnosis of acute suppurative sialadenitis was made.", + "Treatment included copious fluid intake, amoxicillin and clavulanic acid (500 mg/12 5 mg) twice a day for 5 days.", + "Treatment included paracetamol 1000 mg three times a day for 5 days.", + "Treatment included povidone-iodine (Betadine) gargle for 7 days.", + "The infection resolved completely until about a year later when she presented with signs and symptoms as those initially observed.", + "A similar treatment regimen was prescribed.", + "After elimination of the infection, the patency of the right Stensen’s duct was checked by cannulation with no indication of obstruction.", + "About 2 years following her initial submission she presented with a recurrence of the initial signs and symptoms.", + "It was immediately decided to perform a magnetic resonance imaging (MRI) scan.", + "The MRI showed a homogenous well-defined right cheek lesion medial to the buccinator muscle and engulfing the ipsilateral Stensen’s duct.", + "The clinical and radiographic features of the lesion were suggestive of a lipoma.", + "The differential diagnosis of oral dermoid cyst, epidermoid cyst, and lymphoepithelial cysts was considered.", + "A decision was made to excise the lesion via an intraoral approach.", + "The Stensen’s duct was cannulated for localization and protection during the surgery.", + "Following excision of the lesion, histopathology diagnosis confirmed a lipoma of the right cheek area.", + "Immediately following recovery from the surgery, our patient reported complete resolution of previously noted symptoms of pain, discomfort, and swelling that were related to mealtimes.", + "Six months following surgery, our patient is symptom-free and continues to be monitored." + ], + "summary": "We report the case of an intraoral lipoma occurring with signs and symptoms of recurrent sialadenitis in a 15-year-old Kenyan girl of Kikuyu descent. The lipoma was antecedent leading to partial obstruction and stasis related to the right Stensen's duct culminating in recurrent sialadenitis of the ipsilateral parotid gland. Due to the slow growth, softness, diffuse nature and lack of pain, lipomas may exist below the diagnostic radar, hence, the need to have a high index of suspicion and utilize diagnostic aids as necessary. In this case magnetic resonance imaging was key in establishing the existence of the lipoma. The lipoma was excised with resolution of the recurrent sialadenitis.", + "summary_subclaims": [ + "The case involves an intraoral lipoma occurring with signs and symptoms of recurrent sialadenitis in a 15-year-old Kenyan girl of Kikuyu descent.", + "The lipoma was antecedent leading to partial obstruction and stasis related to the right Stensen's duct.", + "The partial obstruction and stasis culminated in recurrent sialadenitis of the ipsilateral parotid gland.", + "Lipomas may exist below the diagnostic radar due to their slow growth, softness, diffuse nature and lack of pain.", + "Magnetic resonance imaging was key in establishing the existence of the lipoma.", + "The lipoma was excised with resolution of the recurrent sialadenitis." + ] + }, + { + "id": "multiclinsum_test_530_en.txt", + "fulltext": "The patient was a 19-year-old female with a height of 163.5 cm and a weight of 21.5 kg. She was born after 38 weeks of gestation and weighed 2624 g without asphyxia, but was diagnosed as having severe MMA at 3 days of age due to deterioration of general status, and the presence of metabolic acidosis and hyperammonemia. Complicating her cerebral palsy, she was repeatedly hospitalized due to acidosis and seizures. Since 2009, her renal function gradually worsened, and in 2017, plasma creatinine (Cr) was found to be above 4.0 mg/dl. In 2018, the patient was admitted to the emergency room due to a deterioration of general status from infection, and an operation for a continuous ambulatory peritoneal dialysis catheter placement was scheduled.\nPreoperative venous blood gas analysis did not indicate metabolic acidosis: pH, 7.432; PCO2, 42.1 mmHg; PO2, 38.2 mmHg; and base excess (BE), 2.9 mEq/l. Blood results showed anemia and renal failure: hemoglobin (Hb), 6.1 g/dl; blood urea nitrogen (BUN), 56.0 mg/dl; Cr, 4.04 mg/dl; and estimated glomerular filtration rate (eGFR), 13 ml/min/L.\nGeneral anesthesia was combined with a peripheral nerve block. No premedication was administered. After the patient entered the operating room, electrocardiography, saturation of percutaneous oxygen, and noninvasive arterial pressure were monitored. Anesthesia was induced using thiamylal (4.6 mg/kg), remifentanil (0.4 mcg/kg/min), and rocuronium (0.9 mg/kg). After tracheal intubation, the patient underwent an ultrasound-guided bilateral rectus sheath block with 0.2% ropivacaine (30 ml). Anesthesia was maintained with a gas mixture of oxygen and air (FiO2 0.4), 1.0 minimum alveolar anesthetic concentration sevoflurane (1.2–2%), and remifentanil (0.2–0.4 mcg/kg/min).\nIntraoperative arterial blood gas values were as follows: pH, 7.369; pCO2, 32.9 mmHg; pO2, 182 mmHg; BE, − 5.9 mEq/l; Na, 140 mmol/l; K, 3.8 mmol/l; and Cl, 104 mmol/l. Glucose preparation was used to prevent hypoglycemia while maintaining a concentration of 100–200 mg/dl to ensure optimal dosing. The preoperative blood sugar level was 113 mg/dl. Hypotonic fluid (2.5% glucose) was used in the perioperative period. Blood sugar level declined to 82 mg/dl during surgery, and 5% glucose was administered. The level was 120 mg/dl at the end of the surgery. To avoid perioperative accumulation of methylmalonic acid, the temperature was maintained above 36.0 °C with a heating device, and clindamycin was administered intravenously. Throughout the surgery, hemodynamic parameters were stable, and the operation was over without using vasopressor agents. Extubation was performed after intravenous administration of sugammadex (4 mg/kg). The duration of surgery was 2 h and 10 min, and that of anesthesia was 3 h and 30 min. Postoperatively, the patient did not experience pain at rest; however, she experienced mild pain during movement. The patient did not use any rescue analgesic agents in the postoperative period. Additionally, no evidence of metabolic acidosis or hyperammonemia (NH3, 29 μg/dl) was observed. Continuous ambulatory peritoneal dialysis was started 10 days after the surgery, and the patient was discharged after 36 days.", + "fulltext_subclaims": [ + "The patient was a 19-year-old female.", + "She was born after 38 weeks of gestation.", + "She weighed 2624 g at birth.", + "She was diagnosed as having severe MMA at 3 days of age.", + "She was diagnosed due to deterioration of general status.", + "She had metabolic acidosis at 3 days of age.", + "She had hyperammonemia at 3 days of age.", + "She had cerebral palsy.", + "She was repeatedly hospitalized due to acidosis.", + "She was repeatedly hospitalized due to seizures.", + "Since 2009, her renal function gradually worsened.", + "In 2017, plasma creatinine was found to be above 4.0 mg/dl.", + "In 2018, the patient was admitted to the emergency room due to a deterioration of general status from infection.", + "An operation for a continuous ambulatory peritoneal dialysis catheter placement was scheduled.", + "Preoperative venous blood gas analysis did not indicate metabolic acidosis.", + "Preoperative pH was 7.432.", + "Preoperative base excess was 2.9 mEq/l.", + "Blood results showed anemia.", + "Blood results showed renal failure.", + "Hemoglobin was 6.1 g/dl.", + "Blood urea nitrogen was 56.0 mg/dl.", + "Plasma creatinine was 4.04 mg/dl.", + "Estimated glomerular filtration rate was 13 ml/min/L.", + "General anesthesia was combined with a peripheral nerve block.", + "No premedication was administered.", + "Anesthesia was induced using thiamylal.", + "Anesthesia was induced using remifentanil.", + "Anesthesia was induced using rocuronium.", + "After tracheal intubation, the patient underwent an ultrasound-guided bilateral rectus sheath block.", + "The rectus sheath block used 0.2% ropivacaine.", + "The rectus sheath block used 30 ml.", + "Anesthesia was maintained with a gas mixture of oxygen and air.", + "Anesthesia was maintained with 1.0 minimum alveolar anesthetic concentration sevoflurane.", + "Anesthesia was maintained with remifentanil.", + "Intraoperative arterial blood gas pH was 7.369.", + "Intraoperative arterial blood gas base excess was −5.9 mEq/l.", + "Glucose preparation was used to prevent hypoglycemia.", + "Glucose concentration was maintained at 100–200 mg/dl.", + "The preoperative blood sugar level was 113 mg/dl.", + "Hypotonic fluid (2.5% glucose) was used in the perioperative period.", + "Blood sugar level declined to 82 mg/dl during surgery.", + "5% glucose was administered during surgery.", + "The temperature was maintained above 36.0 °C with a heating device.", + "Clindamycin was administered intravenously.", + "The operation was over without using vasopressor agents.", + "Extubation was performed after intravenous administration of sugammadex.", + "The duration of surgery was 2 h and 10 min.", + "The duration of anesthesia was 3 h and 30 min.", + "Postoperatively, the patient did not experience pain at rest.", + "The patient experienced mild pain during movement.", + "The patient did not use any rescue analgesic agents in the postoperative period.", + "No evidence of metabolic acidosis was observed.", + "No evidence of hyperammonemia was observed.", + "NH3 was 29 μg/dl.", + "Continuous ambulatory peritoneal dialysis was started 10 days after the surgery.", + "The patient was discharged after 36 days." + ], + "summary": "The patient was a 19-year-old female diagnosed with severe MMA at 3 days of age, who was scheduled for renal replacement therapy. Preoperatively, there was no evidence of metabolic acidosis or electrolyte abnormalities. Glucose was administered preoperatively following a 6-h fast. Anesthesia was administered using thiamylal, remifentanil, rocuronium, and sevoflurane. After tracheal intubation, the patient underwent an ultrasound-guided bilateral rectus sheath block with ropivacaine. A drop in blood sugar level was treated with 5% glucose. Extubation was performed after intravenous administration of sugammadex.", + "summary_subclaims": [ + "The patient was a 19-year-old female diagnosed with severe MMA at 3 days of age.", + "The patient was scheduled for renal replacement therapy.", + "Preoperatively, there was no evidence of metabolic acidosis.", + "Preoperatively, there were no electrolyte abnormalities.", + "Glucose was administered preoperatively following a 6-h fast.", + "Anesthesia was administered using thiamylal, remifentanil, rocuronium, and sevoflurane.", + "The patient underwent an ultrasound-guided bilateral rectus sheath block with ropivacaine.", + "A drop in blood sugar level was treated with 5% glucose.", + "Extubation was performed after intravenous administration of sugammadex." + ] + }, + { + "id": "multiclinsum_test_1023_en.txt", + "fulltext": "In August 2016, a cystoscopically visible protuberant neoplasm of the urinary bladder was found in a 73-year-old man, with clinical manifestation of lower abdominal pain, frequency, urgency and dysuria during urination. Pelvic computed tomography (CT) examination showed a 1.5 cm nodular soft tissue shadow at the left anterior wall of the bladder . The patient then underwent the procedure of transurethral resection of bladder tumor (TURBT). Resected sample was formalin fixed, paraffin embedded. The tissue blocks were cut into 3-μm sections, which were stained with hematoxylin and eosin. Microscopic examination showed the neoplasm was composed of spindle or ovoid-shaped cells that formed storiform, nested or swirling patterns. It involved mucosa and submucosa layers. The neoplastic spindle cells had indistinct cytoplasmic borders, a moderate amount of lightly acidophilic cytoplasm, round or ovoid nuclei with a thin nuclear membrane and small nucleoli. Abundant mitotic Figs. (30 mitoses/10 high-power fields) and apoptotic bodies were present, with no necrosis and hemorrhage. Multinucleated cells and pleomorphic cells were also seen. Some mature lymphocytes infiltrated between tumor cells and in perivascular spaces . The residual lymphoid tissue was limited to small follicles.\nImmunohistochemical stains were performed in our laboratory, utilizing an avidin biotin peroxidase complex method. Heat-induced antigen retrieval was performed and then the tissue was incubated with antibodies. Mouse monoclonal anti-human antibodies against CD3, CD5, CD20, CD21, CD23, CD30, CD56, CK, CK7, EMA, HMB45, Melan A, SMA, Vimentin, rabbit polyclonal anti-human antibodies against S-100, were purchased from Leica company. Mouse monoclonal anti-human antibodies CD35, D2–40, Desmin, Ki-67, MPO, P63, GATA-3, P16, P53, EGFR, ALK, CK5/6, rabbit polyclonal anti-human antibodies against CK20, P40, TFE-3, Uroplakin, were purchased from ZS company. Mouse monoclonal anti-human antibody BRAF V600E (VE1) was purchased from Roche company.\nThe tumor cells were positive for CD21 and vimentin, partly positive for CD23, D2–40 and CD35. The tumor cells were negative for CK, CK5/6, EMA, CK7, CK20, P63, P40, Uroplakin, Desmin, SMA, S100, TFE-3, HMB45, MelanA, MPO, ALK, CD3, CD5, CD20 and CD30. Ki-67 was expressed in about 30% of the tumor cell nuclei . Silver staining demonstrated abundant fibers circumfused each tumor cell. The pathological diagnosis of follicular dendritic cell sarcoma was given based on the morphology and immunohistochemistry.\nSix weeks later, the tumor recurred, which appeared widely based, deeper than the primary surgical scar and was about 1.5 × 2 cm in size. A second transurethral resection was performed and microscopically the FDCS still could be seen in bladder mucosa and submucosa. FDCS tumor cells were similar to those seen in the previous sample, which were spindle-shaped with round or ovoid nuclei with small nucleoli. But the number of mitotic Figs. (10 mitoses/10 high-power fields) was lower than that of the first sample. However, the tumor cells were found to infiltrate in muscularis propria. It was surprising that there was also an invasive urothelial carcinoma that was mixed with the FDCS. The UC of bladder infiltrated in mucosa and submucosa. The tumor cells of UC were arranged in nest or cord pattern, the cytoplasm was acidophilic and the nuclear were irregular. . Using immunohischemistry, UC were positive for CK, CK20, P63, GATA-3, negative for CD21, CD23, CD35 and D2–40. Otherwise, FDCS were positive for Vimentin, CD21, CD23, CD35 and D2–40, negative for CK and CK20. . UC and FDCS were both positive for P16, P53 and EGFR, and both negative for BRAF.\nBecause the second resection site was closed to the first one, we suspected the first sample might have been associated with urothelial carcinoma that was undetected in the first sample. We then obtained deeper levels of the initially resected tumor. Indeed, we identified the urothelial carcinoma in the deeper levels, which was coexisting with FDCS . After the second surgery the patient was treated with chemotherapy. At the time of writing this report, the patient had haven another relapse of urothelial carcinoma and one relapse of follicular dendritic cell sarcoma.", + "fulltext_subclaims": [ + "In August 2016, a cystoscopically visible protuberant neoplasm of the urinary bladder was found in a 73-year-old man.", + "The patient had clinical manifestation of lower abdominal pain, frequency, urgency and dysuria during urination.", + "Pelvic computed tomography (CT) examination showed a 1.5 cm nodular soft tissue shadow at the left anterior wall of the bladder.", + "The patient then underwent the procedure of transurethral resection of bladder tumor (TURBT).", + "The resected sample was formalin fixed, paraffin embedded.", + "The tissue blocks were cut into 3-μm sections, which were stained with hematoxylin and eosin.", + "Microscopic examination showed the neoplasm was composed of spindle or ovoid-shaped cells that formed storiform, nested or swirling patterns.", + "It involved mucosa and submucosa layers.", + "The neoplastic spindle cells had indistinct cytoplasmic borders, a moderate amount of lightly acidophilic cytoplasm, round or ovoid nuclei with a thin nuclear membrane and small nucleoli.", + "Abundant mitotic Figs. (30 mitoses/10 high-power fields) and apoptotic bodies were present, with no necrosis and hemorrhage.", + "Multinucleated cells and pleomorphic cells were also seen.", + "Some mature lymphocytes infiltrated between tumor cells and in perivascular spaces.", + "The residual lymphoid tissue was limited to small follicles.", + "Immunohistochemical stains were performed in our laboratory, utilizing an avidin biotin peroxidase complex method.", + "Heat-induced antigen retrieval was performed and then the tissue was incubated with antibodies.", + "Mouse monoclonal anti-human antibodies against CD3, CD5, CD20, CD21, CD23, CD30, CD56, CK, CK7, EMA, HMB45, Melan A, SMA, Vimentin, rabbit polyclonal anti-human antibodies against S-100, were purchased from Leica company.", + "Mouse monoclonal anti-human antibodies CD35, D2–40, Desmin, Ki-67, MPO, P63, GATA-3, P16, P53, EGFR, ALK, CK5/6, rabbit polyclonal anti-human antibodies against CK20, P40, TFE-3, Uroplakin, were purchased from ZS company.", + "Mouse monoclonal anti-human antibody BRAF V600E (VE1) was purchased from Roche company.", + "The tumor cells were positive for CD21 and vimentin, partly positive for CD23, D2–40 and CD35.", + "The tumor cells were negative for CK, CK5/6, EMA, CK7, CK20, P63, P40, Uroplakin, Desmin, SMA, S100, TFE-3, HMB45, MelanA, MPO, ALK, CD3, CD5, CD20 and CD30.", + "Ki-67 was expressed in about 30% of the tumor cell nuclei.", + "Silver staining demonstrated abundant fibers circumfused each tumor cell.", + "The pathological diagnosis of follicular dendritic cell sarcoma was given based on the morphology and immunohistochemistry.", + "Six weeks later, the tumor recurred, which appeared widely based, deeper than the primary surgical scar and was about 1.5 × 2 cm in size.", + "A second transurethral resection was performed and microscopically the FDCS still could be seen in bladder mucosa and submucosa.", + "FDCS tumor cells were similar to those seen in the previous sample, which were spindle-shaped with round or ovoid nuclei with small nucleoli.", + "The number of mitotic Figs. (10 mitoses/10 high-power fields) was lower than that of the first sample.", + "The tumor cells were found to infiltrate in muscularis propria.", + "There was also an invasive urothelial carcinoma that was mixed with the FDCS.", + "The UC of bladder infiltrated in mucosa and submucosa.", + "The tumor cells of UC were arranged in nest or cord pattern, the cytoplasm was acidophilic and the nuclei were irregular.", + "Using immunohistochemistry, UC were positive for CK, CK20, P63, GATA-3, negative for CD21, CD23, CD35 and D2–40.", + "FDCS were positive for Vimentin, CD21, CD23, CD35 and D2–40, negative for CK and CK20.", + "UC and FDCS were both positive for P16, P53 and EGFR, and both negative for BRAF.", + "Because the second resection site was close to the first one, we suspected the first sample might have been associated with urothelial carcinoma that was undetected in the first sample.", + "We then obtained deeper levels of the initially resected tumor.", + "Indeed, we identified the urothelial carcinoma in the deeper levels, which was coexisting with FDCS.", + "After the second surgery the patient was treated with chemotherapy.", + "At the time of writing this report, the patient had had another relapse of urothelial carcinoma and one relapse of follicular dendritic cell sarcoma." + ], + "summary": "We report an unusual case of follicular dendritic cell sarcoma that is coexistent with urothelial carcinoma (UC) in the urinary bladder of a 73-year-old man, who first presented with lower abdominal pain. Microscopic examination of the first transurethral resection of bladder tumor (TURBT) sample showed a neoplasm containing spindle or ovoid-shaped cells that were arranged in storiform, nested or swirling patterns. Abundant mitotic Figs. (30 mitoses/10 high-power fields) and apoptotic bodies were present. The tumor cells were positive for CD21 and vimentin, partly positive for CD23, D2-40 and CD35. After 6 weeks, the tumor recurred lately, which surprisingly contained a component of urothelial carcinoma. The first TURBT sample was then reviewed and a coexisting UC mixed with FDCS was identified by examining the deeper levels of the tumor blocks.", + "summary_subclaims": [ + "We report an unusual case of follicular dendritic cell sarcoma that is coexistent with urothelial carcinoma (UC) in the urinary bladder of a 73-year-old man.", + "The patient first presented with lower abdominal pain.", + "Microscopic examination of the first transurethral resection of bladder tumor (TURBT) sample showed a neoplasm containing spindle or ovoid-shaped cells.", + "The tumor cells were arranged in storiform, nested or swirling patterns.", + "Abundant mitotic Figs. (30 mitoses/10 high-power fields) and apoptotic bodies were present.", + "The tumor cells were positive for CD21 and vimentin.", + "The tumor cells were partly positive for CD23, D2-40 and CD35.", + "After 6 weeks, the tumor recurred lately.", + "The recurrence contained a component of urothelial carcinoma.", + "The first TURBT sample was then reviewed and a coexisting UC mixed with FDCS was identified by examining the deeper levels of the tumor blocks." + ] + }, + { + "id": "multiclinsum_test_2251_en.txt", + "fulltext": "Here, we present a 29-year-old lady who presented to our hospital with a history of two months of progressive, painless abdominal distension and progressively increasing yellowish discoloration of the eyes. She also had generalized weakness and weight loss of 4.5 kg in the same duration. She denied changes to appetite or bowel habits, melena, hematemesis, and altered sensorium. She had no personal or family history of chronic liver disease, no history of alcohol, or use of any drug or alternative medicine. Besides jaundice, there were no peripheral stigmata of chronic liver disease. Abdominal examination revealed a grossly distended abdomen with fluid thrill consistent with ascites. Similarly, examination of breast revealed a hard, non-tender irregular mobile mass measuring 3cm × 4 cm on the left upper quadrant of the left breast and another hard, non-tender, immobile irregular mass measuring 3cm × 2cm in the lower quadrant of the right breast.\nLiver function tests were deranged with impaired synthetic function. Viral screening and autoantibody tests were negative. Serum Ceruloplasmin level was normal. She had normal alpha-fetoprotein but elevated cancer antigen 125 and carcinoembryonic antigen. Laboratory findings are listed in . Ascitic fluid analysis showed high SAAG (1.7g/dl) and low protein (1.2 g/dl) ascites. Three samples of ascitic fluid for malignant cytology were negative. UGI Endoscopy showed Grade 2 oesophageal varices without any red colour signs and mild portal hypertensive gastropathy.\nAbdominal ultrasound showed hepatomegaly with coarse echotexture and a few well-defined hyperechoic nodules with surrounding hypoechoic rim, ascites, and a patent portal vein without splenomegaly. The chest X-ray was normal. Breast ultrasound showed spiculated, hypoechoic lesion (2.5 × 2.2 × 1.8 cm) in the right breast suspicious of malignancy and multiple well-defined hypoechoic oval lesions in bilateral breasts. Tru-cut biopsy from the right breast showed nests, cords, and a few tubules of tumor-infiltrating the fibro adipose tissue, which was suggestive of infiltrating duct carcinoma (Nottingham Histological score 8, Grade 3), while a tru-cut biopsy from the left breast was suggestive of a fibroepithelial tumor.\nTriple phase CECT showed the enlarged and irregular outline of the liver with multiple variable-sized hypodense lesions with slight enhancement in the arterial phase and washout in the delayed phase with the dilated portal vein (13.4mm) and gross ascites but no splenomegaly (, , ).\nHowever, the patient died after three weeks of presentation to the hospital before any therapeutic measures were initiated concerning the liver metastasis, with the primary being breast carcinoma.", + "fulltext_subclaims": [ + "The patient is a 29-year-old lady.", + "She had two months of progressive, painless abdominal distension.", + "She had progressively increasing yellowish discoloration of the eyes.", + "She had generalized weakness.", + "She had weight loss of 4.5 kg in the same duration.", + "She denied changes to appetite or bowel habits.", + "She denied melena.", + "She denied hematemesis.", + "She had no personal or family history of chronic liver disease.", + "She had no history of alcohol.", + "She had no use of any drug or alternative medicine.", + "Abdominal examination revealed a grossly distended abdomen with fluid thrill consistent with ascites.", + "Examination of the breast revealed a hard, non-tender irregular mobile mass measuring 3cm × 4 cm on the left upper quadrant of the left breast.", + "Examination of the breast revealed another hard, non-tender, immobile irregular mass measuring 3cm × 2cm in the lower quadrant of the right breast.", + "Liver function tests were deranged with impaired synthetic function.", + "Viral screening and autoantibody tests were negative.", + "Serum Ceruloplasmin level was normal.", + "She had normal alpha-fetoprotein.", + "She had elevated cancer antigen 125.", + "She had elevated carcinoembryonic antigen.", + "Ascitic fluid analysis showed high SAAG (1.7g/dl).", + "Ascitic fluid analysis showed low protein (1.2 g/dl).", + "Three samples of ascitic fluid for malignant cytology were negative.", + "UGI Endoscopy showed Grade 2 oesophageal varices without any red colour signs.", + "UGI Endoscopy showed mild portal hypertensive gastropathy.", + "Abdominal ultrasound showed hepatomegaly with coarse echotexture.", + "Abdominal ultrasound showed a few well-defined hyperechoic nodules with surrounding hypoechoic rim.", + "Abdominal ultrasound showed ascites.", + "Abdominal ultrasound showed a patent portal vein without splenomegaly.", + "The chest X-ray was normal.", + "Breast ultrasound showed spiculated, hypoechoic lesion (2.5 × 2.2 × 1.8 cm) in the right breast suspicious of malignancy.", + "Breast ultrasound showed multiple well-defined hypoechoic oval lesions in bilateral breasts.", + "Tru-cut biopsy from the right breast showed nests, cords, and a few tubules of tumor-infiltrating the fibro adipose tissue.", + "Tru-cut biopsy from the right breast was suggestive of infiltrating duct carcinoma.", + "Tru-cut biopsy from the left breast was suggestive of a fibroepithelial tumor.", + "Triple phase CECT showed the enlarged and irregular outline of the liver.", + "Triple phase CECT showed multiple variable-sized hypodense lesions with slight enhancement in the arterial phase.", + "Triple phase CECT showed washout in the delayed phase.", + "Triple phase CECT showed a dilated portal vein (13.4mm).", + "Triple phase CECT showed gross ascites.", + "The patient died after three weeks of presentation to the hospital.", + "The patient died before any therapeutic measures were initiated concerning the liver metastasis.", + "The primary was breast carcinoma." + ], + "summary": "We present the case of a 29-year-old non-alcoholic lady who presented to our hospital with a history of two months of progressive, painless abdominal distension and progressively increasing yellowish discoloration of the eyes. Physical examination, laboratory investigations, and imaging tests led to a diagnosis of multiple metastases from breast carcinoma to the liver leading to portal hypertension after exclusion of other causes of portal hypertension. However, after three weeks of presentation to the hospital, the patient died before any therapeutic measures were initiated to address breast carcinoma.", + "summary_subclaims": [ + "The patient is a 29-year-old non-alcoholic lady.", + "She had a history of two months of progressive, painless abdominal distension.", + "She had progressively increasing yellowish discoloration of the eyes.", + "Physical examination, laboratory investigations, and imaging tests led to a diagnosis of multiple metastases from breast carcinoma to the liver.", + "The diagnosis was of multiple metastases from breast carcinoma to the liver leading to portal hypertension.", + "Other causes of portal hypertension were excluded.", + "The patient died after three weeks of presentation to the hospital.", + "The patient died before any therapeutic measures were initiated to address breast carcinoma." + ] + }, + { + "id": "multiclinsum_test_2218_en.txt", + "fulltext": "A previously healthy 62-year-old woman (BMI = 28.1) experienced progressive low back pain with bilateral hip pain soreness for the past 1 year. The patient's symptoms did not improve significantly after conservative treatment. She complained of back and pelvic pain, which had persisted for the past year. The pain in the lower back was aggravated when standing for a long time and when tired, and the pain was relieved when resting. Japanese orthopaedic association (JOA) score was 19 points, and the low back pain visual analogue scale (VAS) score was 5 points. The neurological examination was normal. Lumbar X-ray positive lateral position, lateral and overextension, overcurved slices showed lumbar 4 (L4) vertebral body instability and slipped forward I degree . Magnetic resonance imaging (MRI) revealed lumbar degeneration and L4 vertebral body slip forward (I degree), corresponding to segmental spinal stenosis, spinal cord and nerve root compression . Lumbar computed tomography (CT) showed: lumbar vertebrae 4 degenerative spondylolisthesis, no fractures in the lumbar isthmus . According to the patient's symptoms, signs and imaging findings, the patient was diagnosed with lumbar degenerative spondylolisthesis (I degree). After completing the preoperative routine examination to eliminate contraindications, the patient underwent elective OLIF surgery under general anesthesia.\nUnder general anesthesia, the patient underwent routine catheterization, and was placed in the right lateral position. Then the skin was shaved and prepared with povidone iodine and draped in a sterile manner. With the L4/L5 intervertebral space as the center, a vertical incision (approximately 4 cm) was made at the level of the left anterior axillary line. The skin and subcutaneous tissue were cut, and the muscle tissue was bluntly separated layer by layer. The peritoneal fat was pushed forward to protect the viscera and other tissues until it touched the psoas muscle. The psoas muscle was pushed backward and the guide needle was placed on the leading edge of the psoas muscle. The expansion cannula was placed step by step, and a fixation screw was placed in the L4/L5 intervertebral space. When placing the self-retaining retractor onto the L4/L5 intervertebral disc, a thread pin, which fixates the retractor through a small hole, went deep into the anterior space of the spinal column. After confirming that the CAGE position was good during the operation, the expansion sleeve was removed, and a large amount of saline was used to rinse the incision. Then double-click electrocoagulation was used to stop the bleeding. It was found that there was a clear liquid flowing out of the peritoneum at the level of the L4/5 segment, and hematuria was found in the catheter . These phenomena indicated that the left ureter may have been damaged. A urinary surgeon was consulted urgently during the operation, and left ureteral injury was definitively diagnosed. Then the patient underwent left ureteral injury exploration and ureteral stent (double pigtail stent, Cook, USI-626-B) placement into the ureter . The original incision was expanded along about 6 cm, and the shape of the left ureter was explored. There was a ureteral leak at the level of the L4/L5 segment. Both ends of the ureteral injury were freed, and the F4.5 short-term ureteral stent (double pigtail stent, cook, USI-626-B) was implanted from the ureteral leak. A 5–0 absorbable thread was used to suture the ureteral end without tension of the ureter. Then, the abdominal incision was closed, and the patient was changed to the prone position. Under the guidance of the C-arm, percutaneous pedicle screws were placed into the L4 and L5 bilateral pedicles. The intraoperative plain film showed the height recovery of the intervertebral disc and the left ureter stent was in a good position . The left ureteral stent was removed 2 months after surgery, and the lumbar spine X-ray showed good spine stability 1 year after surgery .\nThe patient was indwelled with a catheter for 2 weeks, and regular oral administration of levofloxacin to prevent urinary tract infection. After 2 months, the ureteral stent was removed by using cystoscope. One year after surgery, the symptoms of lumbar back were significantly improved (JOA score of 25 point, low back pain VAS score of 1 point), and there were no urinary system symptoms 3 years after surgery. However, the patient still needs to regularly check the left ureter and the left kidney by ultrasound annually.", + "fulltext_subclaims": [ + "The patient is a 62-year-old woman.", + "The patient's BMI was 28.1.", + "The patient experienced progressive low back pain with bilateral hip pain soreness for the past 1 year.", + "The patient's symptoms did not improve significantly after conservative treatment.", + "The patient complained of back and pelvic pain that had persisted for the past year.", + "The lower back pain was aggravated when standing for a long time.", + "The lower back pain was aggravated when tired.", + "The lower back pain was relieved when resting.", + "The Japanese orthopaedic association (JOA) score was 19 points.", + "The low back pain visual analogue scale (VAS) score was 5 points.", + "The neurological examination was normal.", + "Lumbar X-ray showed lumbar 4 (L4) vertebral body instability and slipped forward I degree.", + "Magnetic resonance imaging (MRI) revealed lumbar degeneration.", + "MRI showed L4 vertebral body slip forward (I degree).", + "MRI showed segmental spinal stenosis.", + "MRI showed spinal cord and nerve root compression.", + "Lumbar computed tomography (CT) showed lumbar vertebrae 4 degenerative spondylolisthesis.", + "Lumbar CT showed no fractures in the lumbar isthmus.", + "The patient was diagnosed with lumbar degenerative spondylolisthesis (I degree).", + "The patient underwent elective OLIF surgery under general anesthesia.", + "Under general anesthesia, the patient underwent routine catheterization.", + "The patient was placed in the right lateral position.", + "A vertical incision (approximately 4 cm) was made at the level of the left anterior axillary line.", + "The skin and subcutaneous tissue were cut, and the muscle tissue was bluntly separated layer by layer.", + "The peritoneal fat was pushed forward to protect the viscera and other tissues until it touched the psoas muscle.", + "The psoas muscle was pushed backward and the guide needle was placed on the leading edge of the psoas muscle.", + "A fixation screw was placed in the L4/L5 intervertebral space.", + "A thread pin, which fixates the retractor through a small hole, went deep into the anterior space of the spinal column.", + "During the operation, clear liquid was found flowing out of the peritoneum at the level of the L4/5 segment.", + "Hematuria was found in the catheter.", + "These phenomena indicated that the left ureter may have been damaged.", + "A urinary surgeon was consulted urgently during the operation.", + "Left ureteral injury was definitively diagnosed.", + "The patient underwent left ureteral injury exploration and ureteral stent placement.", + "A F4.5 short-term ureteral stent (double pigtail stent, cook, USI-626-B) was implanted from the ureteral leak.", + "A 5–0 absorbable thread was used to suture the ureteral end without tension of the ureter.", + "The abdominal incision was closed.", + "Under the guidance of the C-arm, percutaneous pedicle screws were placed into the L4 and L5 bilateral pedicles.", + "The intraoperative plain film showed the height recovery of the intervertebral disc.", + "The intraoperative plain film showed the left ureter stent was in a good position.", + "The left ureteral stent was removed 2 months after surgery.", + "Lumbar spine X-ray showed good spine stability 1 year after surgery.", + "The patient was indwelled with a catheter for 2 weeks.", + "The patient received regular oral administration of levofloxacin to prevent urinary tract infection.", + "After 2 months, the ureteral stent was removed by using cystoscope.", + "One year after surgery, the symptoms of lumbar back were significantly improved.", + "One year after surgery, the JOA score was 25 points.", + "One year after surgery, the low back pain VAS score was 1 point.", + "There were no urinary system symptoms 3 years after surgery.", + "The patient still needs to regularly check the left ureter and the left kidney by ultrasound annually." + ], + "summary": "A 62-year-old Chinese woman diagnosed with \"lumbar spondylolisthesis (L4 forward slip, I degree)\" underwent OLIF treatment. The surgical decompression process was smooth, and the cage was successfully placed. After the expansion sleeve of OLIF was removed, clear liquid continuous outflow from the peritoneum was found. The patient was diagnosed with a ureteral injury. The urological surgeon expanded the original incision, and left ureteral injury anastomosis and ureteral stent implantation were performed. The patient was changed to the prone position and a percutaneous pedicle screw was placed in the corresponding vertebral body. The patient was indwelled with a catheter for 2 weeks, and regular oral administration of levofloxacin to prevent urinary tract infection. After 2 months, the double J tube was removed using a cystoscope. One year after surgery, the symptoms of lumbar back were significantly improved, and there were no urinary system symptoms. However, the patient needed an annual left ureter and kidney B-ultrasound.", + "summary_subclaims": [ + "The patient is a 62-year-old Chinese woman.", + "The patient was diagnosed with lumbar spondylolisthesis (L4 forward slip, I degree).", + "The patient underwent OLIF treatment.", + "The surgical decompression process was smooth.", + "The cage was successfully placed.", + "Clear liquid continuous outflow from the peritoneum was found after the expansion sleeve of OLIF was removed.", + "The patient was diagnosed with a ureteral injury.", + "The urological surgeon expanded the original incision.", + "Left ureteral injury anastomosis was performed.", + "Ureteral stent implantation was performed.", + "The patient was changed to the prone position.", + "A percutaneous pedicle screw was placed in the corresponding vertebral body.", + "The patient was indwelled with a catheter for 2 weeks.", + "Regular oral administration of levofloxacin was given to prevent urinary tract infection.", + "After 2 months, the double J tube was removed using a cystoscope.", + "One year after surgery, the symptoms of lumbar back were significantly improved.", + "There were no urinary system symptoms one year after surgery.", + "The patient needed an annual left ureter and kidney B-ultrasound." + ] + }, + { + "id": "multiclinsum_test_1074_en.txt", + "fulltext": "A 48-year-old Sudanese lady, coded as F83–581, presented with an abnormal gait as a manifestation of pure hereditary spastic paraplegia. Her condition started in early childhood with tip-toeing that progressed gradually in severity. At the age of 30 years, she could walk only using two sticks. She did not complain of any additional symptoms apart from occasional muscle cramps. Her parents were distantly related and had no family history of similar conditions. She was not on treatment. On examination, her lower limbs were spastic with severe weakness (power grade 3). There were bilateral deformities in the feet (pes equinovarus on the right and hammertoe on the left) and up-going plantar responses. Her upper limbs were normal except for mild spasticity and hyperreflexia on the right side. The patient (F83–581) had neither signs of cerebellar involvement nor evidence of sensory deficit. She was cooperative, oriented, and had no evidence of intellectual alteration. She could barely walk supported by two sticks, and her gait was spastic. Nerve conduction studies were normal. Brain magnetic resonance imaging (MRI) showed periventricular leukomalacia with scattered ischemic foci in the white matter, cerebellum, and right side of the pons. The isthmus of the corpus callosum was thin, but it could be a normal variant. We noted neither cerebral, brain stem, nor cerebellar atrophy, nor acute ischemic changes on the brain MRI .\nWe extracted DNA from the patient and four of her family members and investigated the patient and one of her healthy siblings, coded F83–582, using whole-exome sequencing . Whole-exome sequencing of the patient revealed a heterozygous variant, NM_001080414.4:c.1993G > A (p.E665K) (rs956104232), in the CCDC88C gene that results in substituting Glutamate at position 665 of the protein for Lysine. Sift , Polyphen2 HDIV , Mutation Taster , Provean and M-cap embedded in VarAFT software predicted this substitution as pathogenic with prediction scores of 0.002, 0.982, 1, − 3.21 and 0.069, respectively. Glutamate at position 665 of CCDC88C is highly conserved during evolution. The CADD score of 25 was also in favor of a pathogenic role of this change. We did not detect other convincing variants that could explain the phenotype in our patient. The variant NM_001080414.4:c.1993G > A (p.E665K) was reported once in the gnomAD v2.1.1 database in an individual of African ancestry and had a global allele frequency of 0.0000032 . Using Sanger sequencing, we validated that the variant NM_001080414.4:c.1993G > A (p.E665K) was heterozygous in the patient and absent in her healthy family members .\nTo validate the pathogenicity of the NM_001080414.4:c.1993G > A (p.E665K) variant, we expressed the CCDC88C cDNA in human embryonic kidney (HEK) 293 cells and assessed its effect on c-Jun N-terminal kinase (JNK) / caspase-3 signaling pathway according to the presence or absence of the variant. Overexpressing CCDC88CE665K mutant protein caused a significant increase of JNK hyperphosphorylation and caspase-3 cleavage compared to the wild type protein, a pattern also seen when overexpressing the known SCA40 pathogenic proteins CCDC88CD43N and CCDC88CR464H . NM_001080414.4:c.1993G > A (p.E665K) was likely a de novo variant, though we did not have DNA samples from the parents. It had a low frequency in gnomAD database, predicted as pathogenic by multiple computational tools, and its pathogenicity was corroborated by functional studies, thus, fulfilling the criteria of likely pathogenic variants according to the American college of medical genetics and genomics guidelines for interpreting sequence variants published in 2015 . We have submitted the variant to the Clinvar database (accession VCV000978819.2).", + "fulltext_subclaims": [ + "The patient is a 48-year-old Sudanese lady.", + "She presented with an abnormal gait as a manifestation of pure hereditary spastic paraplegia.", + "Her condition started in early childhood with tip-toeing.", + "At the age of 30 years, she could walk only using two sticks.", + "She did not complain of any additional symptoms apart from occasional muscle cramps.", + "Her parents were distantly related.", + "Her parents had no family history of similar conditions.", + "She was not on treatment.", + "On examination, her lower limbs were spastic with severe weakness (power grade 3).", + "There were bilateral deformities in the feet (pes equinovarus on the right and hammertoe on the left).", + "There were up-going plantar responses.", + "Her upper limbs were normal except for mild spasticity and hyperreflexia on the right side.", + "The patient had neither signs of cerebellar involvement nor evidence of sensory deficit.", + "She could barely walk supported by two sticks.", + "Her gait was spastic.", + "Nerve conduction studies were normal.", + "Brain MRI showed periventricular leukomalacia with scattered ischemic foci in the white matter, cerebellum, and right side of the pons.", + "The isthmus of the corpus callosum was thin, but it could be a normal variant.", + "We noted neither cerebral, brain stem, nor cerebellar atrophy.", + "We noted no acute ischemic changes on the brain MRI.", + "We extracted DNA from the patient and four of her family members.", + "We investigated the patient and one of her healthy siblings using whole-exome sequencing.", + "Whole-exome sequencing of the patient revealed a heterozygous variant, NM_001080414.4:c.1993G > A (p.E665K) (rs956104232), in the CCDC88C gene.", + "The variant results in substituting Glutamate at position 665 of the protein for Lysine.", + "Sift, Polyphen2 HDIV, Mutation Taster, Provean, and M-cap predicted this substitution as pathogenic.", + "The CADD score of 25 was in favor of a pathogenic role of this change.", + "The variant was reported once in the gnomAD v2.1.1 database in an individual of African ancestry.", + "The global allele frequency of the variant was 0.0000032.", + "Using Sanger sequencing, we validated that the variant was heterozygous in the patient.", + "The variant was absent in her healthy family members.", + "Overexpressing CCDC88CE665K mutant protein caused a significant increase of JNK hyperphosphorylation and caspase-3 cleavage compared to the wild type protein.", + "This pattern was also seen when overexpressing the known SCA40 pathogenic proteins CCDC88CD43N and CCDC88CR464H.", + "The variant was likely a de novo variant.", + "It had a low frequency in the gnomAD database.", + "Its pathogenicity was corroborated by functional studies.", + "It fulfilled the criteria of likely pathogenic variants according to the American College of Medical Genetics and Genomics guidelines for interpreting sequence variants published in 2015.", + "We have submitted the variant to the Clinvar database (accession VCV000978819.2)." + ], + "summary": "A 48-year-old Sudanese female presented with pure early onset hereditary spastic paraplegia. Exome sequencing, in-silico analysis, and Sanger sequencing identified the heterozygous NM_001080414.4:c.1993G > A (p.E665K) variant in CCDC88C as a potential cause of her illness. To explore the pathogenicity of the NM_001080414.4:c.1993G > A (p.E665K) variant, we expressed it in human embryonic kidney 293 cells and assessed its effects on apoptosis. In our experiment, NM_001080414.4:c.1993G > A (p.E665K) induced JNK hyper-phosphorylation and enhanced apoptosis. In contrast to previous reports, our patient developed neurological symptoms in early childhood and showed neither features of cerebellar ataxia, extrapyramidal signs, nor evidence of intellectual involvement.", + "summary_subclaims": [ + "The patient is a 48-year-old Sudanese female.", + "The patient had pure early onset hereditary spastic paraplegia.", + "Exome sequencing, in-silico analysis, and Sanger sequencing identified the heterozygous NM_001080414.4:c.1993G > A (p.E665K) variant in CCDC88C as a potential cause of her illness.", + "The NM_001080414.4:c.1993G > A (p.E665K) variant was expressed in human embryonic kidney 293 cells.", + "The experiment assessed the effects of the NM_001080414.4:c.1993G > A (p.E665K) variant on apoptosis.", + "The NM_001080414.4:c.1993G > A (p.E665K) variant induced JNK hyper-phosphorylation.", + "The NM_001080414.4:c.1993G > A (p.E665K) variant enhanced apoptosis.", + "The patient developed neurological symptoms in early childhood.", + "The patient showed neither features of cerebellar ataxia, extrapyramidal signs, nor evidence of intellectual involvement." + ] + }, + { + "id": "multiclinsum_test_2600_en.txt", + "fulltext": "A 17-year-old Caucasian male presented at our outpatient clinic with a one-week history of painless gradual visual loss in both eyes. Two months prior to the visual symptoms, the patient had a SARS CoV-2 infection (B.1.1.7 subtype), confirmed by polymerase chain reaction (PCR) test. He had mild symptoms and was otherwise healthy and reported no other concurrent infections or any other extraocular/systemic symptoms.\nOn first presentation, best corrected visual acuity (BCVA) was counting fingers on the right eye and 0.1 Snellen on the left eye. Slit lamp biomicroscopy revealed 0.5+ cells in the vitreous in both eyes. Dilated fundus examination revealed creamy confluent yellow-white lesions in the macula in both eyes . Fundus autofluorescence imaging (FAF) revealed slightly hypoautofluorescent spots and patches with faint hyperautofluorescent halos around them . Optical coherence tomography (OCT) showed areas with hyperreflectivity of the outer retinal layers with absence of the ellipsoid zone and the impression of a flat serous retinal detachment. The scans in the choroid under the lesions showed hyperreflectivity and the disorganization of the regular vessel structure, suggesting chorio-retinal infiltrates . Fluorescein angiography (FA) showed early hypofluorescence in the affected areas with hyperfluorescence in late phases , indocyanine-green angiography (ICGA) showed both early and late hypocyanescence . There were no neurological symptoms or signs. The clinical findings were consistent with acute posterior placoid pigment epitheliopathy (APMPPE). A full diagnostic workup (hematology, serum biochemistry, renal and liver function tests, serum angiotensin convertase enzyme, hemoglobin A1c) was initiated including blood tests for additional potential relevant infectious causes (tuberculosis, treponema), all of which came back negative. Chest x-ray showed no pathologies.\nDue to the severely affected vision in both eyes, the patient was started on 50 mg oral prednisolone daily, after which vision began to improve rapidly. At the next follow-up, one week after the initial presentation, BCVA was 0.5 on the right and 0.15 on the left eye. One week later, we began gradual tapering of the prednisolone dose. Over the course of the next few weeks, vision improved to 0.6 on both eyes and the lesions began to appear more demarcated and pigmented with paracentral atrophy. Two months after symptom onset, when prednisolone had been tapered to 12.5 mg per day, the impression of continued inflammatory activity and new lesions in the retinal periphery of both eyes suggested relentless placoid chorioretinitis (RPC) . This prompted a rheumatologic consultation with the aim of switching the patient to steroid-sparing therapy. Simultaneously, an MRI scan was performed, that showed no pathologies and hepatitis B and C tests were negative. Based on the rheumatological consultation and a discussion with the patient, adalimumab treatment with 40 mg every other week was initiated with a continued dose of 12.5 mg prednisolone daily followed by slow tapering of the steroid. Over the course of the next few months, vision improved to 0.9 on both eyes. At month 7 after baseline, the patient had a second PCR-confirmed SARS CoV-2 infection (subtype unknown), that had no further impact on the ocular course. Five months after the start of the adalimumab treatment (at month 9 after onset), the steroid was discontinued and there were no signs of active inflammation. The patient has been followed for a total of 21 months since presentation, at the last visit, 12 months after the discontinuation of the systemic steroid, there was no visible activity suggesting inflammation and vision was 0.9 on the right and 1.0 on the left eye with no subjective visual complaints and with good tolerance of the immunosuppressive treatment. Once the patient has demonstrated no relapses on adalimumab monotherapy for 18–24 months, we plan to increase the dosing interval, thus tapering the immunosuppressive treatment under close clinical observation.", + "fulltext_subclaims": [ + "The patient is a 17-year-old Caucasian male.", + "The patient had a one-week history of painless gradual visual loss in both eyes.", + "Two months prior to the visual symptoms, the patient had a SARS CoV-2 infection.", + "The SARS CoV-2 infection was confirmed by polymerase chain reaction (PCR) test.", + "The SARS CoV-2 infection was of the B.1.1.7 subtype.", + "The patient had mild symptoms during the SARS CoV-2 infection.", + "The patient reported no other concurrent infections.", + "The patient reported no extraocular/systemic symptoms.", + "Best corrected visual acuity (BCVA) was counting fingers on the right eye.", + "Best corrected visual acuity (BCVA) was 0.1 Snellen on the left eye.", + "Slit lamp biomicroscopy revealed 0.5+ cells in the vitreous in both eyes.", + "Dilated fundus examination revealed creamy confluent yellow-white lesions in the macula in both eyes.", + "Fundus autofluorescence imaging (FAF) revealed slightly hypoautofluorescent spots and patches.", + "Fundus autofluorescence imaging (FAF) revealed faint hyperautofluorescent halos around the hypoautofluorescent spots and patches.", + "Optical coherence tomography (OCT) showed areas with hyperreflectivity of the outer retinal layers.", + "Optical coherence tomography (OCT) showed absence of the ellipsoid zone.", + "Optical coherence tomography (OCT) showed the impression of a flat serous retinal detachment.", + "The scans in the choroid under the lesions showed hyperreflectivity.", + "The scans in the choroid under the lesions showed disorganization of the regular vessel structure.", + "The disorganization of the regular vessel structure suggested chorio-retinal infiltrates.", + "Fluorescein angiography (FA) showed early hypofluorescence in the affected areas.", + "Fluorescein angiography (FA) showed hyperfluorescence in late phases.", + "Indocyanine-green angiography (ICGA) showed both early and late hypocyanescence.", + "There were no neurological symptoms or signs.", + "The clinical findings were consistent with acute posterior placoid pigment epitheliopathy (APMPPE).", + "A full diagnostic workup was initiated.", + "Blood tests for tuberculosis and treponema were included in the diagnostic workup.", + "All blood tests for tuberculosis and treponema came back negative.", + "Chest x-ray showed no pathologies.", + "The patient was started on 50 mg oral prednisolone daily.", + "At the next follow-up, one week after the initial presentation, BCVA was 0.5 on the right eye.", + "At the next follow-up, one week after the initial presentation, BCVA was 0.15 on the left eye.", + "One week later, we began gradual tapering of the prednisolone dose.", + "Over the course of the next few weeks, vision improved to 0.6 on both eyes.", + "The lesions began to appear more demarcated and pigmented.", + "The lesions showed paracentral atrophy.", + "Two months after symptom onset, the impression of continued inflammatory activity and new lesions in the retinal periphery of both eyes suggested relentless placoid chorioretinitis (RPC).", + "This prompted a rheumatologic consultation.", + "An MRI scan was performed.", + "The MRI scan showed no pathologies.", + "Hepatitis B and C tests were negative.", + "Adalimumab treatment with 40 mg every other week was initiated.", + "The patient continued 12.5 mg prednisolone daily.", + "Over the course of the next few months, vision improved to 0.9 on both eyes.", + "At month 7 after baseline, the patient had a second PCR-confirmed SARS CoV-2 infection.", + "The second SARS CoV-2 infection had no further impact on the ocular course.", + "Five months after the start of the adalimumab treatment, the steroid was discontinued.", + "There were no signs of active inflammation.", + "The patient has been followed for a total of 21 months since presentation.", + "At the last visit, 12 months after the discontinuation of the systemic steroid, there was no visible activity suggesting inflammation.", + "At the last visit, vision was 0.9 on the right eye.", + "At the last visit, vision was 1.0 on the left eye.", + "The patient had no subjective visual complaints.", + "The patient had good tolerance of the immunosuppressive treatment.", + "Once the patient has demonstrated no relapses on adalimumab monotherapy for 18–24 months, we plan to increase the dosing interval.", + "We plan to taper the immunosuppressive treatment under close clinical observation." + ], + "summary": "A 17-year-old male presented with a one-week history of painless gradual visual loss in both eyes. Two months prior to the visual symptoms, the patient had a SARS CoV-2 infection, confirmed by polymerase chain reaction test. Clinical findings with fundoscopy, optical coherence tomography and fluorescein angiography were consistent with APMPPE. Due to the severely affected vision in both eyes, the patient was started on 50 mg oral prednisolone daily, after which vision began to improve rapidly. Two months after symptom onset during steroid taper, the impression of continued inflammatory activity and new lesions in the retinal periphery of both eyes suggested RPC. Adalimumab 40 mg every other week was initiated with 12.5 mg prednisolone daily followed by slow tapering. Vision improved and five months after the start of the adalimumab treatment, the steroid was discontinued and there were no signs of active inflammation. The patient has been followed for a total of 21 months since presentation, had full visual recovery and good tolerance of the immunosuppressive treatment.", + "summary_subclaims": [ + "The patient is a 17-year-old male.", + "The patient had a one-week history of painless gradual visual loss in both eyes.", + "Two months prior to the visual symptoms, the patient had a SARS CoV-2 infection.", + "The SARS CoV-2 infection was confirmed by polymerase chain reaction test.", + "Clinical findings with fundoscopy, optical coherence tomography and fluorescein angiography were consistent with APMPPE.", + "The patient was started on 50 mg oral prednisolone daily.", + "Vision began to improve rapidly after starting prednisolone.", + "Two months after symptom onset during steroid taper, the impression of continued inflammatory activity and new lesions in the retinal periphery of both eyes suggested RPC.", + "Adalimumab 40 mg every other week was initiated.", + "The prednisolone dose was 12.5 mg daily followed by slow tapering.", + "Vision improved after starting adalimumab.", + "Five months after the start of adalimumab treatment, the steroid was discontinued.", + "There were no signs of active inflammation five months after starting adalimumab.", + "The patient has been followed for a total of 21 months since presentation.", + "The patient had full visual recovery.", + "The patient had good tolerance of the immunosuppressive treatment." + ] + }, + { + "id": "multiclinsum_test_423_en.txt", + "fulltext": "A five-month-old male presented with a nodule in the left corner of the left eye. He was born at 40 weeks’ gestational age, without any abnormality or history of trauma at birth. The lesion was first noted at four months of age. The nodule was 8 millimeters in diameter, tan-orange in color, with central ulceration.\nHis parents consulted a maxillofacial surgeon, who took a partial biopsy from the nodule. After the biopsy, the nodule enlarged and became hemorrhagic and the parents brought their child to the Clinic of Dermatology . In mean time the histological evaluation revealed ulcerated cutaneous cellular proliferation, diffuse infiltrates of mononucleated cells, some of which are characterized by their reniform nuclei, foamy histiocytes and numerous Touton giant cells, admixed with eosinophils.\nImmunohistochemistry yielded results immunoreactive for CD68, weak focal positivity for S-100 protein, but negative for Langerin. These results confirmed that the histiocytes are non-Langerhans cells.\nAfter the diagnosis was made, the child was treated by an ophthalmologist, and examination was within normal limits.", + "fulltext_subclaims": [ + "A five-month-old male presented with a nodule in the left corner of the left eye.", + "He was born at 40 weeks’ gestational age.", + "There was no abnormality or history of trauma at birth.", + "The lesion was first noted at four months of age.", + "The nodule was 8 millimeters in diameter.", + "The nodule was tan-orange in color.", + "The nodule had central ulceration.", + "His parents consulted a maxillofacial surgeon.", + "A partial biopsy was taken from the nodule.", + "After the biopsy, the nodule enlarged and became hemorrhagic.", + "The parents brought their child to the Clinic of Dermatology.", + "Histological evaluation revealed ulcerated cutaneous cellular proliferation.", + "There were diffuse infiltrates of mononucleated cells.", + "Some mononucleated cells were characterized by their reniform nuclei.", + "Foamy histiocytes were present.", + "Numerous Touton giant cells were present.", + "Eosinophils were admixed.", + "Immunohistochemistry was immunoreactive for CD68.", + "There was weak focal positivity for S-100 protein.", + "Immunohistochemistry was negative for Langerin.", + "These results confirmed that the histiocytes are non-Langerhans cells.", + "The child was treated by an ophthalmologist.", + "Examination was within normal limits." + ], + "summary": "We report a case of juvenile xanthogranuloma in a male child with onset in the fourth month of life. He presented with a nodule 8 millimeters in diameter, tan-orange in color, ulcerated in the centre, located on the left corner of the left eye. A biopsy without total excision was performed. After the biopsy, the nodule enlarged to 1.5 cm in diameter and became haemorrhagic. The histologic evaluation and immunohistochemistry analysis resulted in the diagnosis of juvenile xanthogranuloma. For aesthetic reasons the nodule was removed by surgical resection.", + "summary_subclaims": [ + "The patient is a male child.", + "The onset of the lesion was in the fourth month of life.", + "He presented with a nodule 8 millimeters in diameter.", + "The nodule was tan-orange in color.", + "The nodule was ulcerated in the centre.", + "The nodule was located on the left corner of the left eye.", + "A biopsy without total excision was performed.", + "After the biopsy, the nodule enlarged to 1.5 cm in diameter.", + "After the biopsy, the nodule became haemorrhagic.", + "The histologic evaluation and immunohistochemistry analysis resulted in the diagnosis of juvenile xanthogranuloma.", + "For aesthetic reasons the nodule was removed by surgical resection." + ] + }, + { + "id": "multiclinsum_test_2772_en.txt", + "fulltext": "A 30-year-old woman, a nurse, came to the doctor's clinic complaining of left back pain for seven days in June 2021. The patient had no past illness or urological problems history, The family history for urological problems and routine drug consumption was denied. The vital signs were within normal limits, and the physical examination demonstrated normal results, which were no referred pain, mass, or lesions. The patient underwent routine laboratory tests, including CBC, Kidney Function, Liver Function, Urinalysis, and Urine sedimentation, and showed no abnormal results. Therefore, radiologic imaging was carried out for the diagnosis. The USG abdomen showed a cyst on the left kidney. Based on those data, conservative management was the best option for the patient.\nIn July 2021, the patient suddenly felt accompanied by severe pain in the left flank region while carrying her baby. The patient denied any history of strenuous activity and trauma. The patient appeared pale and weak, and her vital sign showed low blood pressure and tachycardia. The laboratory examination results demonstrated anemia and low hematocrit level. The results of a CT-Scan abdomen with contrast showed that there was a hyperdense lesion, a well-defined, regular edge on the left kidney, size ± 7.4 × 7.0 × 7.0 cm, with a calcified component, the lesion appears to compress the left renal pelvis, accompanied by subcapsular fluid collection, density 32 Hounsfield Unit (HU) and gloom in the left fat mesentery reaching the region left lower hemiabdomen . Other findings in the patient included ascites in the pelvic and peri splenic region, bilateral pleural effusion, especially left, hepatomegaly, and thickening of the VU wall. Due to suspicion of spontaneous rupture of the renal cyst, the patient underwent exploration and bleeding control. The exploration results obtained that on the base cyst, there was an active blood vessel that bursts. The operative technique for this condition through cyst excision and nephrorrhaphy was performed by Tarakan Regional Hospital Urologist . Moreover, pathological anatomy analysis demonstrated no malignancy cells found.\nAs a comprehensive treatment, ensuring any abnormality in the following days was mandatory. The patient underwent a routine follow-up for perioperative, one-week post-operative, and a month later. The patient's daily routine had no limitations, without any post-operative adverse effects. This case presentation followed SCARE Guideline Checklist 2020 .", + "fulltext_subclaims": [ + "The patient is a 30-year-old woman.", + "The patient is a nurse.", + "The patient complained of left back pain for seven days in June 2021.", + "The patient had no past illness.", + "The patient had no urological problems history.", + "The family history for urological problems was denied.", + "The patient denied routine drug consumption.", + "The vital signs were within normal limits.", + "The physical examination demonstrated normal results.", + "The patient underwent routine laboratory tests, including CBC, Kidney Function, Liver Function, Urinalysis, and Urine sedimentation.", + "The routine laboratory tests showed no abnormal results.", + "Radiologic imaging was carried out for the diagnosis.", + "The USG abdomen showed a cyst on the left kidney.", + "Conservative management was the best option for the patient.", + "In July 2021, the patient suddenly felt accompanied by severe pain in the left flank region while carrying her baby.", + "The patient denied any history of strenuous activity.", + "The patient denied trauma.", + "The patient appeared pale and weak.", + "The patient's vital sign showed low blood pressure.", + "The patient's vital sign showed tachycardia.", + "The laboratory examination results demonstrated anemia.", + "The laboratory examination results demonstrated low hematocrit level.", + "The results of a CT-Scan abdomen with contrast showed that there was a hyperdense lesion on the left kidney.", + "The lesion was well-defined with a regular edge.", + "The lesion size was ± 7.4 × 7.0 × 7.0 cm.", + "The lesion had a calcified component.", + "The lesion appears to compress the left renal pelvis.", + "There was subcapsular fluid collection.", + "The subcapsular fluid collection had a density of 32 Hounsfield Unit (HU).", + "There was gloom in the left fat mesentery reaching the region left lower hemiabdomen.", + "Other findings included ascites in the pelvic and peri splenic region.", + "Other findings included bilateral pleural effusion, especially left.", + "Other findings included hepatomegaly.", + "Other findings included thickening of the VU wall.", + "Due to suspicion of spontaneous rupture of the renal cyst, the patient underwent exploration and bleeding control.", + "The exploration results obtained that on the base cyst, there was an active blood vessel that bursts.", + "The operative technique for this condition was cyst excision and nephrorrhaphy.", + "The operative technique was performed by Tarakan Regional Hospital Urologist.", + "Pathological anatomy analysis demonstrated no malignancy cells found.", + "The patient underwent a routine follow-up for perioperative.", + "The patient underwent a routine follow-up one-week post-operative.", + "The patient underwent a routine follow-up a month later.", + "The patient's daily routine had no limitations.", + "The patient had no post-operative adverse effects.", + "This case presentation followed SCARE Guideline Checklist 2020." + ], + "summary": "A previously healthy 30-year-old complained of left back pain a few days ago. There were no abnormalities in the physical and laboratory examination, so CT Scan Abdomen with contrast was performed. It was found that there was a 7.4 cm × 7.0 cm × 7.0 cm cyst. The patients undergo conservative management. Three months later, the patient suddenly fell with severe left back pain. Due to suspicion of spontaneous rupture of the renal cyst, the patient underwent exploration and bleeding control.", + "summary_subclaims": [ + "The patient is a previously healthy 30-year-old.", + "The patient complained of left back pain a few days ago.", + "There were no abnormalities in the physical and laboratory examination.", + "CT Scan Abdomen with contrast was performed.", + "A 7.4 cm × 7.0 cm × 7.0 cm cyst was found.", + "The patient underwent conservative management.", + "Three months later, the patient suddenly fell with severe left back pain.", + "Spontaneous rupture of the renal cyst was suspected.", + "The patient underwent exploration and bleeding control." + ] + }, + { + "id": "multiclinsum_test_1866_en.txt", + "fulltext": "A 55-year-old male who underwent a radical surgical procedure was referred to our medical facility for further evaluation and management of a local recurrence of anastomosis. The patient previously underwent laparoscopic high anterior resection and Japanese D2 lymph node dissection after being diagnosed with rectosigmoid cancer at the age of 53 years. According to the ninth edition of the Union for International Cancer Control , rectal cancer was pathologically diagnosed as pT3N0M0 Stage IIA. After surgery, the patient received adjuvant therapy of uracil–tegafur and leucovorin for a year at the previous hospital. He was symptom-free for 1 year and 3 months, and no signs of recurrence were observed.\nOne year and 3 months after the surgery, the serum level of carcinoembryonic antigen increased to 20.2 ng/mL. CT scan indicated the development of a tumor at the anastomosis site that was massively attached to the upper part of the sacrum and a small nodule, and it was suspected that peritoneal dissemination was present on the ventral right side of the anastomosis . In addition, a positron emission tomography–CT scan confirmed an abnormally high accumulation of 2-[18F]-fluoro-2-deoxy-D-glucose on the recurrent lesion . A colonoscopy confirmed the diagnosis of LRRC , and histopathological examination of the biopsy specimens revealed adenocarcinoma cells. LRRC was deemed unresectable for R0 clearance and was genetically characterized as RAS wild type. Therefore, we administered systemic chemotherapy with mFOLFOX6 and panitumumab. The recurrent tumor shrank after 11 rounds of treatment, the diminutive nodule near the anastomosis disappeared, and no signs of distant metastasis were observed. However, the recurring tumor remained in contact with the upper part of the sacrum . We determined that radical surgical resection was still not possible, and CIRT facility was consulted. It was determined that CIRT could not be performed because of the close proximity of the intestinal anastomotic site. This was decided based on the fact that the dose of CIRT is higher than the dose tolerable for the intestinal tract, and its proximity to the intestinal tract can increase the risk of ulcers, bleeding, and perforation. Therefore, it was proposed that the exposed intestinal tract should be removed within 1–2 months after CIRT considering its late toxicities. The patient provided informed consent and selected multidisciplinary therapy incorporating CIRT as the treatment option.\nCIRT was administered daily 4 days/week for 16 fractions. The total irradiated dose was set at 73.6 Gy (relative biological effectiveness–weighted dose [RBE]). The radiation field included the tumor with a 10-mm margin. As a result, approximately 5 cm of the intestinal tract was included in the irradiated area . The patient was re-evaluated 1 month after irradiation with multiple imaging studies, but no significant changes in the tumor were observed. In addition, there were no significant adverse effects in the intestinal tract, except for light erythema, mucosal edema, and erosion at the anastomosis .\nSurgical removal was performed as planned 8 weeks after CIRT. Surgery was performed laparoscopically with regional removal of the intestine. Despite the presence of adhesions that seemed to be related to the prior surgery, no significant adhesions with other organs were detected within the CIRT-irradiated area. In the irradiated area, the tissue was extremely firm owing to severe fibrosis, thus making it difficult to distinguish the dissected layer. Therefore, we proceeded with sharp dissection as close as possible to the sacrum, with the connective tissue being sharply dissected along the sacral surface using monopolar electronic scalpels and ultrasonically activated devices. This dissection line was selected to prevent any exposure of the intestinal lumen. However, sharp dissection resulted in a significant amount of exudate production, thus making it difficult to maintain a clear field of view during the surgical procedure within the pelvis. We verified the anastomosis from the prior surgery using intraoperative colonoscopy. Further, we estimated the extent of irradiated bowel based on the distance from the anastomosis using the preoperative irradiation map as a guide. The physician who designed and performed preoperative CIRT participated in the surgery and provided advice on the resection line. The rectum was resected 2 cm distal to the anastomotic tumor, and the entire irradiated bowel was removed . Re-anastomosis was performed using the double-stapling technique, and a temporary loop ileostomy was constructed. No complications were observed except for a paralytic ileus, which delayed the start of meals for 7 days. Histopathological examination of the removed rectum revealed massive fibrosis and scattered small numbers of cancer cells . The nuclei of these cancer cells showed irregularly marked swelling and chromatin clumping . Because of intimal thickening that contained foamy cells, small vascular lumen was narrowed near these degenerated cancer cells . These morphological changes suggested the presence of the CIRT effect, which was estimated as TRG3 according to the previously proposed criteria . No adjuvant therapy was administered, and tumor markers and imaging were performed every 3 months after the surgery. The temporary ileostomy was closed 8 months after the surgical intervention. The quality of life of the patient, especially defecation function, was maintained. The patient continues to survive with no obvious signs of recurrence 24 months after surgery.", + "fulltext_subclaims": [ + "The patient was referred for further evaluation and management of a local recurrence of anastomosis.", + "The patient previously underwent laparoscopic high anterior resection.", + "The patient previously underwent Japanese D2 lymph node dissection.", + "Rectal cancer was pathologically diagnosed as pT3N0M0 Stage IIA.", + "The patient received adjuvant therapy of uracil–tegafur and leucovorin for a year.", + "The patient was symptom-free for 1 year and 3 months.", + "Serum carcinoembryonic antigen increased to 20.2 ng/mL.", + "CT scan indicated the development of a tumor at the anastomosis site.", + "The tumor was massively attached to the upper part of the sacrum.", + "A small nodule was observed.", + "Peritoneal dissemination was suspected on the ventral right side of the anastomosis.", + "A positron emission tomography–CT scan confirmed an abnormally high accumulation of 2-[18F]-fluoro-2-deoxy-D-glucose on the recurrent lesion.", + "A colonoscopy confirmed the diagnosis of LRRC.", + "Histopathological examination of the biopsy specimens revealed adenocarcinoma cells.", + "LRRC was deemed unresectable for R0 clearance.", + "LRRC was genetically characterized as RAS wild type.", + "Systemic chemotherapy with mFOLFOX6 and panitumumab was administered.", + "The recurrent tumor shrank after 11 rounds of treatment.", + "The diminutive nodule near the anastomosis disappeared.", + "No signs of distant metastasis were observed.", + "The recurring tumor remained in contact with the upper part of the sacrum.", + "Radical surgical resection was still not possible.", + "CIRT facility was consulted.", + "CIRT could not be performed because of the close proximity of the intestinal anastomotic site.", + "The dose of CIRT is higher than the dose tolerable for the intestinal tract.", + "The proximity of CIRT to the intestinal tract can increase the risk of ulcers, bleeding, and perforation.", + "It was proposed that the exposed intestinal tract should be removed within 1–2 months after CIRT.", + "The patient provided informed consent.", + "Multidisciplinary therapy incorporating CIRT was selected as the treatment option.", + "CIRT was administered daily 4 days/week for 16 fractions.", + "The total irradiated dose was set at 73.6 Gy (relative biological effectiveness–weighted dose [RBE]).", + "The radiation field included the tumor with a 10-mm margin.", + "Approximately 5 cm of the intestinal tract was included in the irradiated area.", + "The patient was re-evaluated 1 month after irradiation with multiple imaging studies.", + "No significant changes in the tumor were observed.", + "There were no significant adverse effects in the intestinal tract.", + "Light erythema was observed at the anastomosis.", + "Mucosal edema was observed at the anastomosis.", + "Erosion was observed at the anastomosis.", + "Surgical removal was performed 8 weeks after CIRT.", + "Surgery was performed laparoscopically with regional removal of the intestine.", + "The tissue in the irradiated area was extremely firm owing to severe fibrosis.", + "Sharp dissection was performed as close as possible to the sacrum.", + "The connective tissue was sharply dissected along the sacral surface using monopolar electronic scalpels and ultrasonically activated devices.", + "The dissection line was selected to prevent any exposure of the intestinal lumen.", + "Sharp dissection resulted in a significant amount of exudate production.", + "Intraoperative colonoscopy was used to verify the anastomosis from the prior surgery.", + "The extent of irradiated bowel was estimated based on the distance from the anastomosis using the preoperative irradiation map.", + "The physician who designed and performed preoperative CIRT participated in the surgery.", + "The rectum was resected 2 cm distal to the anastomotic tumor.", + "The entire irradiated bowel was removed.", + "Re-anastomosis was performed using the double-stapling technique.", + "A temporary loop ileostomy was constructed.", + "No complications were observed except for a paralytic ileus.", + "The paralytic ileus delayed the start of meals for 7 days.", + "Histopathological examination of the removed rectum revealed massive fibrosis.", + "Scattered small numbers of cancer cells were observed.", + "The nuclei of these cancer cells showed irregularly marked swelling and chromatin clumping.", + "Small vascular lumen was narrowed near these degenerated cancer cells.", + "These morphological changes suggested the presence of the CIRT effect.", + "The CIRT effect was estimated as TRG3 according to the previously proposed criteria.", + "No adjuvant therapy was administered.", + "Tumor markers and imaging were performed every 3 months after the surgery.", + "The temporary ileostomy was closed 8 months after the surgical intervention.", + "The quality of life of the patient, especially defecation function, was maintained.", + "The patient continues to survive with no obvious signs of recurrence 24 months after surgery." + ], + "summary": "A 55-year-old male was diagnosed with an anastomotic recurrence of rectal cancer 15 months after undergoing anterior resection. Computed tomography (CT) suggested that the lesion was at an anastomosis site and broadly adherent to the upper sacrum, and colonoscopy confirmed the diagnosis of LRRC. Histopathological examination of the biopsy specimens revealed adenocarcinoma cells and that lesion was genetically RAS-wild. Induction chemotherapy with mFOLFOX6 and panitumumab was used as the first treatment. The recurrent lesion shrank and no signs of distant metastasis were observed after 11 cycles, although the range of the lesions attached to the sacrum remained unchanged. Therefore, we provided CIRT for this inoperable lesion and prophylactically removed the radiation-exposed bowel including the recurrent lesion, because radiation-induced ulcers can cause bleeding and perforation. Despite the presence of considerable fibrosis in the irradiated region, the operation was successful and the postoperative course had no untoward incidents. He is still recurrence-free 24 months following surgery, despite the lack of adjuvant chemotherapy. This is the first report of CIRT followed by CIRT-irradiated bowel removal for an unresectable anastomosis recurrent lesion.", + "summary_subclaims": [ + "A 55-year-old male was diagnosed with an anastomotic recurrence of rectal cancer 15 months after undergoing anterior resection.", + "Computed tomography suggested that the lesion was at an anastomosis site and broadly adherent to the upper sacrum.", + "Colonoscopy confirmed the diagnosis of LRRC.", + "Histopathological examination of the biopsy specimens revealed adenocarcinoma cells.", + "The lesion was genetically RAS-wild.", + "Induction chemotherapy with mFOLFOX6 and panitumumab was used as the first treatment.", + "The recurrent lesion shrank after 11 cycles.", + "No signs of distant metastasis were observed after 11 cycles.", + "The range of the lesions attached to the sacrum remained unchanged.", + "CIRT was provided for this inoperable lesion.", + "Prophylactically, the radiation-exposed bowel including the recurrent lesion was removed.", + "Radiation-induced ulcers can cause bleeding and perforation.", + "Despite the presence of considerable fibrosis in the irradiated region, the operation was successful.", + "The postoperative course had no untoward incidents.", + "He is still recurrence-free 24 months following surgery.", + "There was no adjuvant chemotherapy.", + "This is the first report of CIRT followed by CIRT-irradiated bowel removal for an unresectable anastomosis recurrent lesion." + ] + }, + { + "id": "multiclinsum_test_702_en.txt", + "fulltext": "A 10-year-old boy started to develop craniofacial deformities 2 years ago.\nThe patient’s mother reported that the child began to develop craniofacial deformities, accompanied by nasal deformities, uneven dentition, and abnormal occlusion. No significant hearing loss or symptoms of increased intracranial pressure were observed.\nAt the age of 3 years, the child had a closed craniocerebral trauma without surgical treatment. There was no history of surgery, hepatitis, tuberculosis, or other special medical history.\nThe patient had no other personal or family history. The appearance characteristics of the child at the ages of 3, 5, 8, and 10 years are shown in Figure .\nDevelopmental malformation of the head and face, with a head circumference of 52.3 cm, maxillofacial malformation , and abnormal structure of the cheekbones, nasal bones, mandibles, and maxillary sinus bones were observed. Bilateral eyeball protrusion of 16 mm, uneven oral dentition, with most of the teeth in the entire mouth missing, and abnormal occlusion were also seen. Mouth opening was limited to only two fingers (or 3 cm), and severe wear was seen on the posterior teeth. Varicose veins were observed on the skin of the lower jaw. No coffee-like pigmentation was observed on the facial skin. There was no deformity in both auricles, the external auditory meatus on both sides was narrow, and the tympanic membrane could not be clearly seen. The nasal mucosa on both sides was congested, the total nasal meatus was narrow and clear mucus was visible, and no neoplasms were found in the middle nasal meatus. Pure tone audiometry showed binaural mixed hearing loss (left ear air conduction [AC]: 63 dB, bone conduction [BC]: 55 dB; right ear AC: 68 dB, BC: 51 dB).\nAlkaline phosphatase level was 1296 U/L (normal range: 40-150 U/L), and other biochemical indicators were basically normal. Pituitary level of luteinizing hormone was 2.58 mIU/mL (normal range: 16-53 mIU/mL), follicle stimulating hormone was 1.10 mIU/mL (normal range: 3.3-8.0 mIU/mL), estradiol was 79 ng/L (normal range: 6-53 ng/L), testosterone was 15.2 μg/L (normal range: 3-5.7 μg/L), and prolactin was 52.25 μg/L (normal range: 16-53 μg/L). 25-Hydroxyvitamin D was 70.2 nmol/L (normal reference: > 75 nmol/L), osteocalcin was 385 μg/L (normal reference: 4-10 μg/L), and growth hormone was 2.105 ng/mL. The thyroid function and routine blood and urine tests were basically normal. The child's guardians refused genetic testing.\nThe whole body X-ray showed abnormal proliferation of multiple bone fibers in the bilateral tibia, femur, humerus, ulna, radius, and skull . High resolution computed tomography of the temporal bone indicated diffuse thickening and increased density of the maxillofacial bone, skull, and atlas axis. The thickest part of the frontal bone was approximately 3.7 cm, and no gasification was observed in the maxillary sinus, ethmoid sinus, frontal sinus, sphenoid sinus, and mastoid air chambers on both sides. The bony parts of the external auditory meatus on both sides were narrow, with a width of about 3.8 mm and 2.3 mm on the right and left sides, respectively. Bilateral middle ear tympanic cavities and sinuses were narrow, and there were no abnormalities in bilateral ossicles and inner ear structures .", + "fulltext_subclaims": [ + "The patient is a 10-year-old boy.", + "The patient started to develop craniofacial deformities 2 years ago.", + "The patient’s mother reported that the child began to develop craniofacial deformities.", + "The patient had nasal deformities.", + "The patient had uneven dentition.", + "The patient had abnormal occlusion.", + "No significant hearing loss was observed.", + "No symptoms of increased intracranial pressure were observed.", + "At the age of 3 years, the child had a closed craniocerebral trauma.", + "The child did not receive surgical treatment for the closed craniocerebral trauma.", + "There was no history of surgery.", + "There was no history of hepatitis.", + "There was no history of tuberculosis.", + "The patient had no other personal or family history.", + "Developmental malformation of the head and face was observed.", + "The head circumference was 52.3 cm.", + "Maxillofacial malformation was observed.", + "Abnormal structure of the cheekbones was observed.", + "Abnormal structure of the nasal bones was observed.", + "Abnormal structure of the mandibles was observed.", + "Abnormal structure of the maxillary sinus bones was observed.", + "Bilateral eyeball protrusion of 16 mm was observed.", + "Uneven oral dentition was observed.", + "Most of the teeth in the entire mouth were missing.", + "Abnormal occlusion was observed.", + "Mouth opening was limited to only two fingers.", + "Severe wear was seen on the posterior teeth.", + "Varicose veins were observed on the skin of the lower jaw.", + "No coffee-like pigmentation was observed on the facial skin.", + "No deformity was observed in both auricles.", + "The external auditory meatus on both sides was narrow.", + "The tympanic membrane could not be clearly seen.", + "The nasal mucosa on both sides was congested.", + "The total nasal meatus was narrow.", + "Clear mucus was visible in the total nasal meatus.", + "No neoplasms were found in the middle nasal meatus.", + "Pure tone audiometry showed binaural mixed hearing loss.", + "The left ear air conduction was 63 dB.", + "The left ear bone conduction was 55 dB.", + "The right ear air conduction was 68 dB.", + "The right ear bone conduction was 51 dB.", + "Alkaline phosphatase level was 1296 U/L.", + "The normal range for alkaline phosphatase is 40-150 U/L.", + "Pituitary level of luteinizing hormone was 2.58 mIU/mL.", + "The normal range for luteinizing hormone is 16-53 mIU/mL.", + "Follicle stimulating hormone was 1.10 mIU/mL.", + "The normal range for follicle stimulating hormone is 3.3-8.0 mIU/mL.", + "Estradiol was 79 ng/L.", + "The normal range for estradiol is 6-53 ng/L.", + "Testosterone was 15.2 μg/L.", + "The normal range for testosterone is 3-5.7 μg/L.", + "Prolactin was 52.25 μg/L.", + "The normal range for prolactin is 16-53 μg/L.", + "25-Hydroxyvitamin D was 70.2 nmol/L.", + "The normal reference for 25-Hydroxyvitamin D is > 75 nmol/L.", + "Osteocalcin was 385 μg/L.", + "The normal reference for osteocalcin is 4-10 μg/L.", + "Growth hormone was 2.105 ng/mL.", + "The thyroid function was basically normal.", + "Routine blood and urine tests were basically normal.", + "The child's guardians refused genetic testing.", + "The whole body X-ray showed abnormal proliferation of multiple bone fibers in the bilateral tibia.", + "The whole body X-ray showed abnormal proliferation of multiple bone fibers in the bilateral femur.", + "The whole body X-ray showed abnormal proliferation of multiple bone fibers in the bilateral humerus.", + "The whole body X-ray showed abnormal proliferation of multiple bone fibers in the bilateral ulna.", + "The whole body X-ray showed abnormal proliferation of multiple bone fibers in the bilateral radius.", + "The whole body X-ray showed abnormal proliferation of multiple bone fibers in the skull.", + "High resolution computed tomography of the temporal bone indicated diffuse thickening and increased density of the maxillofacial bone.", + "High resolution computed tomography of the temporal bone indicated diffuse thickening and increased density of the skull.", + "High resolution computed tomography of the temporal bone indicated diffuse thickening and increased density of the atlas axis.", + "The thickest part of the frontal bone was approximately 3.7 cm.", + "No gasification was observed in the maxillary sinus.", + "No gasification was observed in the ethmoid sinus.", + "No gasification was observed in the frontal sinus.", + "No gasification was observed in the sphenoid sinus.", + "No gasification was observed in the mastoid air chambers on both sides.", + "The bony parts of the external auditory meatus on both sides were narrow.", + "The width of the right bony part of the external auditory meatus was about 3.8 mm.", + "The width of the left bony part of the external auditory meatus was about 2.3 mm.", + "Bilateral middle ear tympanic cavities were narrow.", + "Bilateral sinuses were narrow.", + "No abnormalities were found in bilateral ossicles.", + "No abnormalities were found in bilateral inner ear structures." + ], + "summary": "A 10-year-old boy attended our outpatient clinic due to craniofacial malformations found two years ago. He underwent temporal bone computed tomography and digital radiography photography. Based on a literature review combined with the patient's medical history and imaging examination findings, he was diagnosed with multiple fibrous dysplasia of bone. As the clinical symptoms related to MAS in this patient were not obvious, he was only followed up and not given any special treatment.", + "summary_subclaims": [ + "A 10-year-old boy attended our outpatient clinic due to craniofacial malformations found two years ago.", + "He underwent temporal bone computed tomography and digital radiography photography.", + "Based on a literature review combined with the patient's medical history and imaging examination findings, he was diagnosed with multiple fibrous dysplasia of bone.", + "The clinical symptoms related to MAS in this patient were not obvious.", + "He was only followed up and not given any special treatment." + ] + }, + { + "id": "multiclinsum_test_3188_en.txt", + "fulltext": "A 30-year-old woman with a history of rheumatoid arthritis on long-term methotrexate and a previous hospital admission for a complicated fungal urinary tract infection (UTI) presented to her gynecologist with 1 week of vaginal discharge, vaginal pruritus, and bilateral flank pain. Urine and vaginal cultures were obtained, and she was started on intravaginal clotrimazole while awaiting results. The vaginal and urine cultures obtained by her gynecologist were notable for heavy growth of S cerevisiae that was susceptible to voriconazole, clotrimazole, flucytosine, and amphotericin B, and her infectious disease doctor was notified. Due to a limited availability of outpatient flucytosine and rapid development of resistance with monotherapy and poor urinary concentration of other antifungals, the patient was admitted by infectious disease for intravenous amphotericin B deoxycholate.\n\nSix months prior, the patient was admitted for refractory fungal vulvovaginitis and complicated C glabrata pyelonephritis. At that time, the patient reported nearly a 7-month history of flank pain, vaginal pruritus and discharge, and dysuria refractory to multiple courses of azole therapy. Urine cultures during that hospitalization were positive for azole-resistant C glabrata. Infectious disease was consulted and recommended treatment with a 7-day course of amphotericin B deoxycholate. The patient completed treatment with resolution of symptoms. Outpatient follow-up cultures were negative for C glabrata.\n\nUpon arrival at the hospital, the patient reported subjective fever, bilateral flank pain, joint pain, and dysuria. In the setting of her infectious symptoms, the patient had stopped her methotrexate at the recommendation of her rheumatologist, leading to worsening rheumatic joint pain. On admission, her vital signs included a temperature of 37.1°C, heart rate of 72 beats per minute, blood pressure of 124/70 mmHg, respiratory rate of 18, and an SpO2 of 99% on room air. Physical examination was remarkable for bilateral costovertebral angle and suprapubic tenderness to palpation. There was no abdominal distention, rebound, or guarding. Cardiac, pulmonary, and neurologic examinations were unremarkable. Complete blood count on admission demonstrated mild leukopenia with a white blood cell (WBC) count of 4.56 (normal: 4.80-10.80 K/cumm) and mild anemia with a hemoglobin of 11.8 (normal: 12.0-16.0 g/dL). Her comprehensive metabolic panel was unremarkable. Urinalysis demonstrated a specific gravity of 1.042 (normal: 1.003-1.030), <1 WBC (normal ≤ 3/HPF), few bacteria, few mucous, and 15 squamous epithelial cells (normal ≤ 5/HPF). Computed tomography of the abdomen and pelvis showed bilateral striated nephrograms and perinephric fat stranding, which, paired with her clinical presentation, was consistent with a diagnosis of fungal pyelonephritis.\n\nThe patient was started on intravenous (IV) amphotericin B deoxycholate, which, despite its nephrotoxicity, was selected over liposomal amphotericin B for its superior urinary concentration. After initiation of antifungal therapy, her flank pain slowly improved as did her pelvic symptoms. Urine cultures collected upon admission resulted on hospital day 5 and confirmed S cerevisiae but also grew Klebsiella pneumoniae. Intravenous ertapenem for the Klebsiella was started once the care team was made aware of the urine culture result. Of note, the patient did have clinical improvement prior to the initiation of ertapenem. Discussion of possible sources of S cerevisiae exposure revealed that the patient had an active sourdough starter in her home which she fed and stirred daily. She completed a 7-day course of IV amphotericin B deoxycholate for the S cerevisiae and transitioned from IV ertapenem to ciprofloxacin (based on sensitivities) for a 10-day course of treatment for the Klebsiella. She was discharged home with close follow-up.", + "fulltext_subclaims": [ + "The patient is a 30-year-old woman.", + "She has a history of rheumatoid arthritis.", + "She is on long-term methotrexate.", + "She had a previous hospital admission for a complicated fungal urinary tract infection.", + "She presented with 1 week of vaginal discharge.", + "She had vaginal pruritus.", + "She had bilateral flank pain.", + "Urine and vaginal cultures were obtained.", + "She was started on intravaginal clotrimazole.", + "The vaginal and urine cultures were notable for heavy growth of S cerevisiae.", + "S cerevisiae was susceptible to voriconazole.", + "S cerevisiae was susceptible to clotrimazole.", + "S cerevisiae was susceptible to flucytosine.", + "S cerevisiae was susceptible to amphotericin B.", + "Her infectious disease doctor was notified.", + "The patient was admitted by infectious disease for intravenous amphotericin B deoxycholate.", + "Six months prior, the patient was admitted for refractory fungal vulvovaginitis.", + "Six months prior, the patient had complicated C glabrata pyelonephritis.", + "At that time, the patient reported nearly a 7-month history of flank pain.", + "At that time, the patient had vaginal pruritus and discharge.", + "At that time, the patient had dysuria refractory to multiple courses of azole therapy.", + "Urine cultures during that hospitalization were positive for azole-resistant C glabrata.", + "Infectious disease recommended treatment with a 7-day course of amphotericin B deoxycholate.", + "The patient completed treatment with resolution of symptoms.", + "Outpatient follow-up cultures were negative for C glabrata.", + "Upon arrival at the hospital, the patient reported subjective fever.", + "She had bilateral flank pain.", + "She had joint pain.", + "She had dysuria.", + "She had stopped her methotrexate at the recommendation of her rheumatologist.", + "This led to worsening rheumatic joint pain.", + "On admission, her temperature was 37.1°C.", + "Physical examination was remarkable for bilateral costovertebral angle tenderness.", + "Physical examination was remarkable for suprapubic tenderness.", + "Computed tomography of the abdomen and pelvis showed bilateral striated nephrograms.", + "Computed tomography showed perinephric fat stranding.", + "This was consistent with a diagnosis of fungal pyelonephritis.", + "The patient was started on intravenous amphotericin B deoxycholate.", + "Amphotericin B deoxycholate was selected over liposomal amphotericin B.", + "After initiation of antifungal therapy, her flank pain slowly improved.", + "Urine cultures collected upon admission resulted on hospital day 5.", + "Urine cultures confirmed S cerevisiae.", + "Urine cultures also grew Klebsiella pneumoniae.", + "Intravenous ertapenem for the Klebsiella was started.", + "The patient did have clinical improvement prior to the initiation of ertapenem.", + "The patient had an active sourdough starter in her home.", + "She fed and stirred the sourdough starter daily.", + "She completed a 7-day course of IV amphotericin B deoxycholate.", + "She transitioned from IV ertapenem to ciprofloxacin.", + "She was discharged home with close follow-up." + ], + "summary": "Our patient is a 30-year-old woman with a history of rheumatoid arthritis on methotrexate, and previous admission for Candida glabrata UTI requiring intravenous antifungal therapies, who presented to her gynecologist with complaints of vaginitis and flank pain. Vaginal and urine cultures grew S cerevisiae, and the patient was diagnosed with pyelonephritis and admitted for treatment. A further review of the patient's history revealed daily exposure to S cerevisiae through baking sourdough bread. She was treated with 7 days of IV amphotericin deoxycholate and discharged on a 6-month course of suppressive oteseconazole for vulvovaginitis suppression.", + "summary_subclaims": [ + "The patient is a 30-year-old woman.", + "The patient has a history of rheumatoid arthritis.", + "The patient is on methotrexate.", + "The patient had a previous admission for Candida glabrata UTI.", + "The patient received intravenous antifungal therapies.", + "The patient presented with complaints of vaginitis and flank pain.", + "Vaginal and urine cultures grew S cerevisiae.", + "The patient was diagnosed with pyelonephritis.", + "The patient was admitted for treatment.", + "The patient has daily exposure to S cerevisiae through baking sourdough bread.", + "The patient was treated with 7 days of IV amphotericin deoxycholate.", + "The patient was discharged on a 6-month course of suppressive oteseconazole." + ] + }, + { + "id": "multiclinsum_test_766_en.txt", + "fulltext": "A 19-year-old male was referred to our department after initial physical examination to a military training center as part of his compulsory enlistment for the Greek military service. During the examination, he reported having a solitary right kidney but was otherwise asymptomatic with no further relevant details. Neither a history of trauma nor previous surgeries were reported. Physical examination was unremarkable. He had no scars on the trunk and normal external genitalia. No pain provoked or masses felt during palpation. A digital rectal examination was not performed due to the patient’s preference. No sexual intercourse was reported at the time. Furthermore, no previous notable medical history for hereditary or acquired diseases was mentioned. The whole blood count and urinalysis results were within normal limits.\nAbdominopelvic computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis were performed. CT depicted only a right kidney with absence of left kidney . Additionally, CT demonstrated a large lobulated multicystic lesion of left seminal vesicle without enhancement on contrast-enhanced images . A saccular dilated ectopic ureter opening into the left cystic seminal vesicle and extending centrally up to the level of L3 vertebral body was revealed with a length of approximately 16 cm .\nMRI was performed with a Siemens Magnetom Avanto (1.5 Tesla) MRI unit (Siemens Inc., Germany) using a pelvic phased-array coil. The imaging protocol comprised T1-weighted, T2-weighted, T2-weighted with fat saturation (FS) and T1-weighted FS images on axial, sagittal and coronal planes. Finally, images on T1-weighted FS sequence after intravenous administration of contrast medium (gadolinium) were added.\nMRI demonstrated a large lobulated multicystic lesion in the anatomic region of left seminal vesicle. The lesion measured approximately 7.2 cm × 6.1 cm with low signal intensity on T2-weighted FS and high signal on T1-weighted images, corresponding to a dilated seminal vesicle cyst (SVC). The high signal intensity on T1-weighted sequences was strongly suggestive of proteinaceous or hematic content. In contrast, the normal right seminal vesicle exhibits high and intermediate signal intensity on T2-weighted FS and T1-weighted images, respectively, corresponding to fluid . An enlargement of the left ejaculatory duct communicating with the dilated SVC was well depicted on sagittal T2-weighted images . A saccular dilated ectopic left ureter with tortuous morphology, which was also filled with proteinaceous or hematic content, was revealed on all T1-weighted images, communicating with the SVC and extending centrally .\nUnfortunately, the patient declined additional investigation by means of transrectal ultrasonography (TRUS), which might have assisted in clarifying the ejaculatory duct obstruction.\nSemen analysis revealed cryptozoospermia (volume < 1 ml, pH 8.0, total sperm count 126 /ml) of obstructive origin. Nevertheless, fertility was not the patient’s primary concern. He declined further management, although he was made aware of the rarity of the syndrome and the possible future need of surgical management. Despite detailed analysis of the importance of cryopreservation and fertility maintenance, he had no intention to cryopreserve sperm or undergo microsurgical sperm retrieval at the time. Therefore, annual semen analysis was recommended for as long as he presented with altered fertility status. Although SVCs are generally benign and rarely symptomatic, cases of malignant transformation and late diagnosis due to the absence of warning symptoms have been described . Thus, we adequately informed our patient about the possibility of the carcinomatous evolution of SVCs. Finally, we advised him to undergo ultrasonographic monitoring on an annual basis.", + "fulltext_subclaims": [ + "The patient is a 19-year-old male.", + "He was referred to the department after initial physical examination at a military training center.", + "He reported having a solitary right kidney.", + "He was otherwise asymptomatic.", + "He had no history of trauma.", + "He had no previous surgeries.", + "Physical examination was unremarkable.", + "He had no scars on the trunk.", + "No pain was provoked during palpation.", + "A digital rectal examination was not performed due to the patient’s preference.", + "The whole blood count was within normal limits.", + "Urinalysis results were within normal limits.", + "Abdominopelvic CT was performed.", + "MRI of the pelvis was performed.", + "CT depicted only a right kidney.", + "CT demonstrated a large lobulated multicystic lesion of the left seminal vesicle.", + "The multicystic lesion showed no enhancement on contrast-enhanced CT images.", + "A saccular dilated ectopic ureter opening into the left cystic seminal vesicle was revealed.", + "The ectopic ureter extended centrally up to the level of the L3 vertebral body.", + "The ectopic ureter had a length of approximately 16 cm.", + "MRI was performed with a Siemens Magnetom Avanto (1.5 Tesla) MRI unit.", + "MRI demonstrated a large lobulated multicystic lesion in the anatomic region of the left seminal vesicle.", + "The lesion measured approximately 7.2 cm × 6.1 cm.", + "The lesion had low signal intensity on T2-weighted fat-saturated images.", + "The lesion had high signal intensity on T1-weighted images.", + "The high signal intensity on T1-weighted sequences was strongly suggestive of proteinaceous or hematic content.", + "The right seminal vesicle exhibited high signal intensity on T2-weighted fat-saturated images.", + "The right seminal vesicle exhibited intermediate signal intensity on T1-weighted images.", + "An enlargement of the left ejaculatory duct communicating with the dilated seminal vesicle cyst was well depicted on sagittal T2-weighted images.", + "A saccular dilated ectopic left ureter with tortuous morphology was revealed on all T1-weighted images.", + "The ectopic ureter was filled with proteinaceous or hematic content.", + "The ectopic ureter communicated with the seminal vesicle cyst.", + "The patient declined transrectal ultrasonography.", + "Semen analysis revealed cryptozoospermia.", + "The semen volume was less than 1 ml.", + "The semen pH was 8.0.", + "The total sperm count was 126 /ml.", + "The cryptozoospermia was of obstructive origin.", + "Fertility was not the patient’s primary concern.", + "The patient declined further management.", + "The patient was informed about the rarity of the syndrome.", + "The patient was informed about the possible future need of surgical management.", + "The patient declined cryopreservation of sperm.", + "The patient declined microsurgical sperm retrieval.", + "Annual semen analysis was recommended.", + "SVCs are generally benign.", + "SVCs are rarely symptomatic.", + "Cases of malignant transformation of SVCs have been described.", + "Cases of late diagnosis of SVCs due to absence of warning symptoms have been described.", + "The patient was informed about the possibility of carcinomatous evolution of SVCs.", + "The patient was advised to undergo ultrasonographic monitoring on an annual basis." + ], + "summary": "Herein, we present a case of a 19-year-old male who reported having a solitary right kidney when examined in a military training center of Northern Greece. No additional clinical information was available; thus, referral to a tertiary urology department for further investigation ensued. Imaging studies, namely, computed tomography and magnetic resonance imaging, revealed left renal aplasia, multiple left seminal vesicle cysts, and ejaculatory duct obstruction. Laboratory values and urinalysis were within normal range. Semen analysis was significant for cryptozoospermia. Our patient remained asymptomatic during the entire hospitalization. Long-term follow-up was recommended. Nevertheless, he declined further investigation and sought treatment in a private practice setting.", + "summary_subclaims": [ + "The patient is a 19-year-old male.", + "The patient reported having a solitary right kidney.", + "The report was made in a military training center of Northern Greece.", + "No additional clinical information was available.", + "The patient was referred to a tertiary urology department for further investigation.", + "Imaging studies included computed tomography and magnetic resonance imaging.", + "Imaging revealed left renal aplasia.", + "Imaging revealed multiple left seminal vesicle cysts.", + "Imaging revealed ejaculatory duct obstruction.", + "Laboratory values were within normal range.", + "Urinalysis was within normal range.", + "Semen analysis was significant for cryptozoospermia.", + "The patient remained asymptomatic during the entire hospitalization.", + "Long-term follow-up was recommended.", + "The patient declined further investigation.", + "The patient sought treatment in a private practice setting." + ] + }, + { + "id": "multiclinsum_test_187_en.txt", + "fulltext": "A 53-year old married female, known case of Depressive disorder for the last 02 years on medication with poor compliance presented to our hospital with an alleged history of attempted suicide by ingesting Organo-phosphorous (OP) compound (composition not known) 02 months back. The patient was managed for OP poisoning in ICU following which a psychiatric consult was sought. She gave a month’s history of persistent sadness of mood; loss of interest in previously pleasurable activities, easy fatigability; significantly reduced sleep, appetite, and minimal to none social interactions since around 03 months. She would at times exhibit bouts of anger outbursts without any apparent cause, followed by periods of extreme hypo-activity manifested by sitting alone in a particular posture. Gradually, the symptoms worsened and 5–6 days before she was brought to the hospital, she had become almost mute and would remain confined to her bed. It was observed by her family members that she was mumbling to the self along with hand gesticulations in the air and had to be consistently coaxed for eating/elimination needs. Patient firmly believed that people around her including family members were talking ill about her and were planning to somehow get rid of her. On further probing, patient justified her beliefs by considering herself as a burden on her family members in view of her long-standing non-remitting illness. She also acknowledged thoughts of self-harm as her last resort to put an end to her suffering. Then, on the fateful day, the patient consumed an unquantified volume of rat poison kept in the storehouse with an intent to die. She was found lying on the floor by family members smelling of garlic odour and was then brought to hospital. She gave past history of fracture left forearm with uneventful complete recovery (open reduction and internal fixation under GA) 16 years back. There was no family history of psychiatric illnesses. Personal history was characterized by anxious-avoidant traits with low stress tolerance. There was no history of any substance use in dependent/abuse pattern. On examination, her pulse was 86/min and blood pressure (BP) was 126/88 mmHg. She was ill kempt, had severe psychomotor retardation, mutism, depressed mood with flat affect, depressive cognitions of helplessness and hopelessness along with mood congruent delusions of reference and persecution. She denied any perceptual abnormalities in clear sensorium and had poor insight with deranged biorhythms. Relevant investigations including NCCT head, renal function tests, serum electrolytes, random blood glucose levels, electrocardiogram, liver function tests, and thyroid profile were within normal limits. An impression of a severe depressive episode with psychotic symptoms was made (ICD 10 F32.3). Patients and family members were counseled regarding treatment options and ECT was offered as the first choice, which was declined by patient as well as family members. She was then started on Cap Fluoxetine 20 mg OD along with Tab Olanzapine 5 mg HS and Tab clonazepam 01 mg HS. Her family members were counseled to be on vigilant round the clock monitoring, ensure patients compliance for medication, and a weekly review in the OPD. Patient however, did not show any significant improvement over the next 1 month despite gradually uptitrating her antidepressants and intensive Cognitive behaviour therapy (CBT) sessions. The patient was still having persistent sadness of mood with severe psychomotor retardation, active suicidal intent, and significantly impaired sleep and appetite. She was hence, again offered MECT as a treatment option, which was agreed upon by patient as well as family members.\nThe patient was now slated for MECT under general anaesthesia (GA). Pre-anaesthesia checkup (PAC) was done, in which a detailed history of the medications taken and past history was taken. Her son gave a history of OP poisoning a month back (38 days), and it was endorsed in the record. With proper advice, she was accepted in ASA Physical Status II (for mental illness on medication) for MECT under GA.\nThe patient was taken up for MECT. The patient had stable hemodynamics. Patient weighed 62 kgs, and was premedicated with Inj Glycopyrolate 0.2 mg, Inj Midazolam 1 mg, Inj Propofol 70 mg and a subminimal dose of Inj Scolene (15 mg, ie < 0.3 mg/kg) due to the prior history of OP poisoning.\nMECT was given by the psychiatrist after complete muscle paralysis with a current constant machine. After GTCS, the patient was oxygenated by bag and mask ventilation. However, the patient did not resume spontaneous breathing even after 10 min. The expected time to return of spontaneous breathing after a full dose of succinylcholine is 9–11 min . Despite the minimal dose of succinylcholine that was administered in this case, and having an adequate time gap since the episode of poisoning (38 days), the patient regained spontaneous breathing only after 3 h. Hemodynamics were stable throughout. Her ABG was done to assess status and all values were within normal limits. On the day of the procedure, there was no ventilator readily available in the ICU to handle this contingency, since such a complication is not anticipated routinely. Hence, the patient was ventilated using an i-gel and bag ventilation with occasional boluses (10 mg) of Inj Propofol. After the patient was fully conscious and regained full sensory and motor function, she was kept admitted for 24 h under observation in the HDU. She was asymptomatic throughout and was discharged the next day. Her psychotropic medications (as mentioned earlier) were continued, excluding Clonazepam. The subsequent 06 MECTs (every third day) were administered using alternative muscle relaxants pancuronium following which she had significant improvement in her mood symptoms without any side-effects/complications. She was then continued on medications along with CBT and was advised weekly OPD reviews with the psychiatrist.\nTo rule out any other cause and confirm diagnosis of suxamethonium apnea, her serum butyrylcholinesterase were checked, and the levels were as low as 240 u/l (normal reference range is 5900 and 13,200 u/l) . Dibucaine and fluoride numbers were not analysed (due to lack of testing facility). Her family was also investigated to rule out genetic involvement, and their levels were within normal limits. Patient’s serum salicylate levels were negative, and RFTs were normal.", + "fulltext_subclaims": [ + "The patient is a 53-year-old married female.", + "She has a known case of Depressive disorder for the last 02 years.", + "She was on medication with poor compliance.", + "She presented with an alleged history of attempted suicide by ingesting an OP compound 02 months back.", + "The composition of the OP compound was not known.", + "She was managed for OP poisoning in ICU.", + "A psychiatric consult was sought.", + "She gave a month’s history of persistent sadness of mood.", + "She had loss of interest in previously pleasurable activities.", + "She had easy fatigability.", + "She had significantly reduced sleep.", + "She had significantly reduced appetite.", + "She had minimal to none social interactions.", + "She exhibited bouts of anger outbursts without any apparent cause.", + "She had periods of extreme hypo-activity.", + "She had become almost mute and confined to her bed.", + "She was mumbling to herself and had hand gesticulations.", + "She had to be consistently coaxed for eating/elimination needs.", + "She firmly believed that people around her were talking ill about her.", + "She believed that people were planning to get rid of her.", + "She justified her beliefs by considering herself a burden on her family.", + "She acknowledged thoughts of self-harm as her last resort.", + "She consumed an unquantified volume of rat poison with an intent to die.", + "She was found lying on the floor by family members.", + "She had a garlic odor.", + "She had a past history of fracture left forearm 16 years back.", + "She had an uneventful complete recovery from the fracture.", + "There was no family history of psychiatric illnesses.", + "Her personal history was characterized by anxious-avoidant traits.", + "There was no history of any substance use in dependent/abuse pattern.", + "On examination, her pulse was 86/min.", + "Her blood pressure was 126/88 mmHg.", + "She had severe psychomotor retardation.", + "She had mutism.", + "She had a depressed mood with flat affect.", + "She had depressive cognitions of helplessness and hopelessness.", + "She had mood congruent delusions of reference and persecution.", + "She denied any perceptual abnormalities.", + "She had poor insight.", + "Relevant investigations were within normal limits.", + "An impression of a severe depressive episode with psychotic symptoms was made.", + "ECT was offered as the first choice.", + "ECT was declined by the patient and family members.", + "She was started on Cap Fluoxetine 20 mg OD.", + "She was started on Tab Olanzapine 5 mg HS.", + "She was started on Tab Clonazepam 01 mg HS.", + "She did not show any significant improvement over the next 1 month.", + "She was again offered MECT.", + "MECT was agreed upon by the patient and family members.", + "The patient was slated for MECT under general anaesthesia.", + "A pre-anaesthesia checkup was done.", + "Her son gave a history of OP poisoning 38 days back.", + "She was accepted in ASA Physical Status II.", + "The patient weighed 62 kgs.", + "She was premedicated with Inj Glycopyrolate 0.2 mg.", + "She was premedicated with Inj Midazolam 1 mg.", + "She was premedicated with Inj Propofol 70 mg.", + "A subminimal dose of Inj Scolene (15 mg) was administered.", + "The patient did not resume spontaneous breathing after 10 min.", + "The patient regained spontaneous breathing after 3 h.", + "Hemodynamics were stable throughout.", + "Her ABG was within normal limits.", + "There was no ventilator readily available in the ICU.", + "The patient was ventilated using an i-gel and bag ventilation.", + "The patient was kept admitted for 24 h under observation.", + "She was asymptomatic throughout.", + "She was discharged the next day.", + "Clonazepam was excluded from her medications.", + "Six MECTs were administered every third day.", + "Alternative muscle relaxants pancuronium were used.", + "She had significant improvement in her mood symptoms.", + "She had no side-effects or complications.", + "Her psychotropic medications were continued.", + "Her serum butyrylcholinesterase levels were 240 u/l.", + "The normal reference range for butyrylcholinesterase is 5900 to 13,200 u/l.", + "Dibucaine and fluoride numbers were not analysed.", + "Her family's butyrylcholinesterase levels were within normal limits.", + "Her serum salicylate levels were negative.", + "Her renal function tests were normal." + ], + "summary": "A 53/F patient consumed OP 38 days prior to MECT. Since existing literature recommend a delay of 4 weeks and a subminimal dose of suxamethonium to prevent prolonged apnea, both these points were taken into consideration. Despite 38 days post exposure to OP, and a dose of succinylcholine of < 0.3 mg/kg, the patient remained apneic for 3 h. Suxamethionum apnea was managed with elective ventilation. After recovery, patient had no residual effect. Subsequently her pseudocholinesterase levels were done which were found to be very low.", + "summary_subclaims": [ + "The patient is a 53-year-old female.", + "The patient consumed OP 38 days prior to MECT.", + "Existing literature recommend a delay of 4 weeks before using suxamethonium after OP exposure.", + "Existing literature recommend a subminimal dose of suxamethonium to prevent prolonged apnea.", + "The patient received a dose of succinylcholine of < 0.3 mg/kg.", + "The patient remained apneic for 3 h.", + "Suxamethionum apnea was managed with elective ventilation.", + "After recovery, the patient had no residual effect.", + "The patient's pseudocholinesterase levels were found to be very low." + ] + }, + { + "id": "multiclinsum_test_2552_en.txt", + "fulltext": "This is the case of a 54-year-old male patient who received a kidney transplant from a living donor, his wife, in December 2014. His underlying nephropathy was a focal and segmental glomerulosclerosis, presumed secondary to a genetic mutation since he had a strong family history of kidney disease, even though no genetic testing was performed. He had been on hemodialysis for 6 months before transplantation. He had no previous blood transfusions, his panel reactive antibodies (PRAs) was negative and he had 5 mismatches in class I and was fully matched in class II. He received an induction therapy with Basiliximab and was maintained on tacrolimus, mycophenolate mofetil (MMF), and low- dose steroids. His immediate post-operative period was uneventful with a serum creatinine of 1.1 mg/dl upon discharge. He continued his regular out-patient follow-up, with no major events, a stable kidney function, and no proteinuria up until August 2020. In September 2020, he presented with fatigue, fever and tested positive with COVID-19 infection. His respiratory symptoms were mild with no oxygen requirements; therefore, he was treated with acetaminophen and oral hydration. His low-grade fever persisted for more than one week, so a chest CT was ordered and showed multiple well-defined ground-glass opacities in both lungs consistent with COVID-19 infection. A blood test was done then and showed a c-reactive protein of 14 mg/l, white blood cells of 5.3 × 109/L with 70% neutrophils and 20% lymphocytes, and a serum creatinine level of 1.4 mg/dl. Since the patient presented with a mild case of COVID-19 he was not treated with dexamethasone, monoclonal antibodies or any other medications. His MMF was decreased from 1500 to 1000 mg per day for a total of 10 days, and his tacrolimus trough levels were kept within target range (6.8 ng/ml). His serum creatinine returned to its baseline of 1.2 mg/dl after resolution of the infection. Later on, it started to fluctuate on higher values reaching 1.6 mg/dl in April 2021, with no evident explanation. There was no introduction of new medications, no intercurrent infections, and again a stable tacrolimus trough level. He was therefore admitted for a kidney biopsy.\nLight microscopy showed histological evidence of global glomerulitis (g2), moderate capillaritis (ptc2) and thrombotic microangiopathy (TMA) affecting arterioles and glomeruli . A single focus of tubulitis was noted (t0). These histopathological findings were consistent with an active AMR. Interestingly, there was no C4d staining of peritubular capillaries or vasa recta upon immunohistochemistry (C4d0). Only focal interstitial inflammation (i0, < 10% of unscarred cortical parenchyma) was noted with CD3 and CD20 immunostaining. Capillaries contained mainly CD3+ and CD4+ T-cells, with some CD56+ cells . Direct immunofluorescence studies showed IgM, C3, and C1q deposition in a segmental distribution in the lesioned glomeruli, consistent with focal and segmental glomerulosclerosis. Some podocytes protein resorption droplets were highlighted by IgA, Kappa, and Lambda. There was no significant IgG deposition nor mesangial IgA deposits. Donor-specific antibodies came back positive for class I, HLA-Cw17, with an MFI of 6689 confirming the diagnosis of late active c4d negative AMR.\nThe patient was also tested for killer cell Ig-like receptors (KIRs) genotyping using the KIR SSO Genotyping Test (One Lambda) which applies Luminex® technology, and came back positive for the expression of KIR2DS1.\nThe patient was treated with pulse steroids, five sessions of plasma exchange and IVIG with a total dose of 2 g/kg, with a good response to treatment and a creatinine at 1.3 mg/dl upon discharge. His DSA decreased three months later to an MFI of 2710, with a delta MFI of 60%.", + "fulltext_subclaims": [ + "The patient is a 54-year-old male.", + "He received a kidney transplant from a living donor in December 2014.", + "The donor was his wife.", + "His underlying nephropathy was focal and segmental glomerulosclerosis.", + "The focal and segmental glomerulosclerosis was presumed secondary to a genetic mutation.", + "He had a strong family history of kidney disease.", + "No genetic testing was performed.", + "He had been on hemodialysis for 6 months before transplantation.", + "He had no previous blood transfusions.", + "His panel reactive antibodies (PRAs) were negative.", + "He had 5 mismatches in class I.", + "He was fully matched in class II.", + "He received induction therapy with Basiliximab.", + "He was maintained on tacrolimus, mycophenolate mofetil (MMF), and low-dose steroids.", + "His immediate post-operative period was uneventful.", + "His serum creatinine was 1.1 mg/dl upon discharge.", + "He had no major events until August 2020.", + "He had stable kidney function until August 2020.", + "He had no proteinuria until August 2020.", + "In September 2020, he presented with fatigue and fever.", + "He tested positive for COVID-19 infection.", + "His respiratory symptoms were mild with no oxygen requirements.", + "He was treated with acetaminophen and oral hydration.", + "His low-grade fever persisted for more than one week.", + "A chest CT showed multiple well-defined ground-glass opacities in both lungs.", + "The chest CT findings were consistent with COVID-19 infection.", + "A blood test showed a c-reactive protein of 14 mg/l.", + "A blood test showed white blood cells of 5.3 × 109/L.", + "A blood test showed 70% neutrophils.", + "A blood test showed 20% lymphocytes.", + "A blood test showed a serum creatinine level of 1.4 mg/dl.", + "He was not treated with dexamethasone.", + "He was not treated with monoclonal antibodies.", + "His MMF was decreased from 1500 to 1000 mg per day.", + "The MMF decrease lasted for a total of 10 days.", + "His tacrolimus trough levels were kept within target range.", + "His tacrolimus trough level was 6.8 ng/ml.", + "His serum creatinine returned to baseline after resolution of the infection.", + "His serum creatinine was 1.2 mg/dl after resolution of the infection.", + "His serum creatinine started to fluctuate on higher values.", + "His serum creatinine reached 1.6 mg/dl in April 2021.", + "There was no introduction of new medications.", + "There were no intercurrent infections.", + "His tacrolimus trough level was stable.", + "He was admitted for a kidney biopsy.", + "Light microscopy showed histological evidence of global glomerulitis (g2).", + "Light microscopy showed moderate capillaritis (ptc2).", + "Light microscopy showed thrombotic microangiopathy affecting arterioles and glomeruli.", + "A single focus of tubulitis was noted (t0).", + "These findings were consistent with an active AMR.", + "There was no C4d staining of peritubular capillaries or vasa recta.", + "Only focal interstitial inflammation (i0) was noted.", + "The interstitial inflammation was < 10% of unscarred cortical parenchyma.", + "Capillaries contained mainly CD3+ and CD4+ T-cells.", + "Some CD56+ cells were noted.", + "Direct immunofluorescence showed IgM, C3, and C1q deposition in a segmental distribution.", + "The IgM, C3, and C1q deposition was in lesioned glomeruli.", + "The findings were consistent with focal and segmental glomerulosclerosis.", + "Some podocytes showed protein resorption droplets.", + "The protein resorption droplets were highlighted by IgA, Kappa, and Lambda.", + "There was no significant IgG deposition.", + "There were no mesangial IgA deposits.", + "Donor-specific antibodies were positive for class I, HLA-Cw17.", + "The donor-specific antibodies had an MFI of 6689.", + "The diagnosis was late active c4d negative AMR.", + "The patient was tested for killer cell Ig-like receptors (KIRs) genotyping.", + "The KIR genotyping used the KIR SSO Genotyping Test (One Lambda).", + "The KIR genotyping used Luminex® technology.", + "The patient was positive for the expression of KIR2DS1.", + "The patient was treated with pulse steroids.", + "The patient received five sessions of plasma exchange.", + "The patient received IVIG with a total dose of 2 g/kg.", + "He had a good response to treatment.", + "His creatinine was 1.3 mg/dl upon discharge.", + "His DSA decreased three months later.", + "His DSA had an MFI of 2710.", + "The delta MFI was 60%." + ], + "summary": "Here we try to find this association by presenting the case of a low immunological risk patient who presented, six years post-transplant, with c4d negative antibody mediated rejection due to an anti-HLA-C17 de novo donor specific antibody (DSA) after contracting the coronavirus disease 19. The HLA-Cw17 activated the antibody-dependent cell-mediated cytotoxicity via the KIR2DS1 positive NK cells.", + "summary_subclaims": [ + "The patient was a low immunological risk individual.", + "The patient presented six years post-transplant.", + "The patient had c4d negative antibody mediated rejection.", + "The rejection was due to an anti-HLA-C17 de novo donor specific antibody.", + "The rejection occurred after contracting the coronavirus disease 19.", + "The HLA-Cw17 activated the antibody-dependent cell-mediated cytotoxicity.", + "The activation was via the KIR2DS1 positive NK cells." + ] + }, + { + "id": "multiclinsum_test_153_en.txt", + "fulltext": "A 72-year-old woman was referred to our clinic with a complaint of decreased visual acuity for 1 wk following cataract surgery performed in the left eye 2 wk ago.\nThe patient underwent an uneventful phacoemulsification cataract surgery for the left eye at our department 2 wk ago, and a rotationally asymmetric refractive multifocal IOL (SBL-3, Lenstec, Inc.) was chosen and implanted with the near segments placed inferonasally. The first day post-surgery, uncorrected distance visual acuity (UDVA) was 0.0 logMAR (20/20 Snellen) and uncorrected near visual acuity (UNVA) was 0.1 logMAR (20/25 Snellen). Preoperative biometric data are given in Table .\nThe patient had bilateral primary angle closure glaucoma treated by laser peripheral iridectomy before at a local hospital, bilateral intraocular pressure was normal with no glaucoma medication before cataract surgery, and she had no history of allergies, trauma, surgery, or systemic disease.\nThe patient was married and had two sons. She had no family history of ocular disease.\nThe patient presented to our clinic for reexamination with deterioration in the UDVA to 1.0 logMAR (20/200 Snellen) and in the corrected distant visual acuity of 1.0 logMAR (20/200 Snellen). Using a slit lamp, the swelling of the corneal endothelium and proliferation of lens epithelial cells crawling over the surface of the IOL could be clearly seen. Meanwhile, the IOL was in positive position, without any tilt or decentration, and the near segment was located in inferonasal orientation .", + "fulltext_subclaims": [ + "The patient is a 72-year-old woman.", + "She was referred to the clinic with a complaint of decreased visual acuity for 1 wk.", + "The decreased visual acuity followed cataract surgery performed in the left eye 2 wk ago.", + "The patient underwent an uneventful phacoemulsification cataract surgery for the left eye at our department 2 wk ago.", + "A rotationally asymmetric refractive multifocal IOL (SBL-3, Lenstec, Inc.) was chosen and implanted.", + "The near segments of the IOL were placed inferonasally.", + "On the first day post-surgery, uncorrected distance visual acuity (UDVA) was 0.0 logMAR (20/20 Snellen).", + "On the first day post-surgery, uncorrected near visual acuity (UNVA) was 0.1 logMAR (20/25 Snellen).", + "The patient had bilateral primary angle closure glaucoma treated by laser peripheral iridectomy before at a local hospital.", + "Bilateral intraocular pressure was normal with no glaucoma medication before cataract surgery.", + "She had no history of allergies, trauma, surgery, or systemic disease.", + "The patient had no family history of ocular disease.", + "At presentation, UDVA had deteriorated to 1.0 logMAR (20/200 Snellen).", + "At presentation, corrected distant visual acuity was 1.0 logMAR (20/200 Snellen).", + "Using a slit lamp, the swelling of the corneal endothelium was observed.", + "Using a slit lamp, proliferation of lens epithelial cells crawling over the surface of the IOL was observed.", + "The IOL was in positive position.", + "The IOL showed no tilt or decentration.", + "The near segment of the IOL was located in inferonasal orientation." + ], + "summary": "A 72-year-old woman with bilateral glaucoma underwent phacoemulsification in the dominant eye (left eye) with implantation of an asymmetrical multifocal IOL. Postoperative uncorrected distance visual acuity (UDVA) was 0.0 logMAR (20/20 Snellen) and uncorrected near visual acuity (UNVA) was 0.1 logMAR (20/25 Snellen). Two weeks later, the patient presented to our clinic with decreased vision due to migration of lens epithelial cells to IOL anterior surface and edema of corneal endothelial cells. Anterior capsule polishing and superotemporal placement of near segment", + "summary_subclaims": [ + "The patient is a 72-year-old woman.", + "The patient has bilateral glaucoma.", + "The patient underwent phacoemulsification in the dominant eye.", + "The dominant eye is the left eye.", + "An asymmetrical multifocal IOL was implanted.", + "Postoperative uncorrected distance visual acuity was 0.0 logMAR.", + "Postoperative uncorrected near visual acuity was 0.1 logMAR.", + "Two weeks later, the patient presented with decreased vision.", + "The cause of decreased vision was migration of lens epithelial cells to IOL anterior surface.", + "The cause of decreased vision was edema of corneal endothelial cells.", + "Anterior capsule polishing was performed.", + "A superotemporal placement of near segment was performed." + ] + }, + { + "id": "multiclinsum_test_3370_en.txt", + "fulltext": "The 8-year-old girl had complained of intermittent fever for the past year and rashes all over her body that started to appear at about 6 months of age. She experienced an oil massage at the age of 6 months, which resulted in the rapid emergence of well-defined elevated skin rashes across her entire body that vanished in minutes. The rashes began to appear every day. There was no connection between these rashes and the use of oil, no discernible pattern to the rash's onset, no disruption of sleep at night, and no prior history of fever, eczema, food, medication, or insect allergies. The rashes continued to appear without any specific pattern daily. They always resolved within one to 2 h without any medication, and they were not itchy. Their parents expected she would outgrow it with time; thus, no further doctor visits or follow-ups were done. At the age of 7 years, she developed high-grade intermittent fever, for which she required admission. But fever continued to appear often, without any specific pattern. After experiencing on-and-off fever for 4 months, a positive Mantoux test, and a chest X-ray revealing a hilar shadow, she was later started on antitubercular medications. GeneXpert sputum yielded negative results. Fever did not, however, go away entirely. She reported to us at this time that she had a daily history of intermittent fever, with most episodes occurring after dark. She exhibited good activity during the inter-febrile phase and had a healthy appetite. Mother had a history of non-pruritic hives all over her body that were worse during a fever and when her skin was exposed. Hives were more common on exposed bodily parts. Antipyretics were used to treat fever and minor joint pain. There was no prior history of edema, redness, involvement of other joints, involvement of the eyes, or repeated hospitalizations. No significance was found in birth, developmental, or family history. Upon general examination, the patient had pallor and well-defined raised lesions over the body. She measured 125 cm (at the 50th centile) in height and 23 kg (25th to 50th centile). A systemic evaluation revealed no abnormalities. The results of the investigation showed neutrophilic leukocytosis (WBC: 22,740/μL, ANC: 16,470/μL) and iron deficiency anemia (Hb: 8.4 g/dL, serum iron: 30 μg/dL, TIBC: 500 μg/dL, transferrin saturation: 8%, ferritin: 15 ng/mL), high CRP of 70 mg/dL, and raised ESR (25 mm at 1 h). Pure tone audiometry revealed right-sided severe mixed hearing loss. Antineutrophilic antibody (ANA), immunoglobulins, and interleukin levels were all within normal limits. Serum amyloid level was high (295 mg/L). The complaints above of hearing loss, elevated amyloid levels, and inflammatory markers led to the suspicion of Muckle-Wells syndrome. Germline mutations in the NLRP3 gene were detected by Sanger sequencing test. A pediatric rheumatologist advised following up a month after starting Colchicine empirically to prevent amyloidosis. There were fewer events still occurring, so the next plan was to begin Anakinra.", + "fulltext_subclaims": [ + "The 8-year-old girl had complained of intermittent fever for the past year.", + "She had rashes all over her body that started to appear at about 6 months of age.", + "She experienced an oil massage at the age of 6 months.", + "The oil massage resulted in the rapid emergence of well-defined elevated skin rashes across her entire body that vanished in minutes.", + "The rashes began to appear every day.", + "There was no connection between these rashes and the use of oil.", + "There was no discernible pattern to the rash's onset.", + "There was no disruption of sleep at night.", + "There was no prior history of fever, eczema, food, medication, or insect allergies.", + "The rashes continued to appear without any specific pattern daily.", + "The rashes always resolved within one to 2 h without any medication.", + "The rashes were not itchy.", + "The parents expected she would outgrow it with time.", + "No further doctor visits or follow-ups were done.", + "At the age of 7 years, she developed high-grade intermittent fever.", + "She required admission for the high-grade intermittent fever.", + "Fever continued to appear often, without any specific pattern.", + "After experiencing on-and-off fever for 4 months, a positive Mantoux test was noted.", + "A chest X-ray revealed a hilar shadow.", + "She was later started on antitubercular medications.", + "GeneXpert sputum yielded negative results.", + "Fever did not go away entirely.", + "She reported a daily history of intermittent fever.", + "Most fever episodes occurred after dark.", + "She exhibited good activity during the inter-febrile phase.", + "She had a healthy appetite.", + "Mother had a history of non-pruritic hives all over her body.", + "The mother's hives were worse during a fever and when her skin was exposed.", + "Hives were more common on exposed bodily parts.", + "Antipyretics were used to treat fever and minor joint pain.", + "There was no prior history of edema, redness, involvement of other joints, involvement of the eyes, or repeated hospitalizations.", + "No significance was found in birth, developmental, or family history.", + "Upon general examination, the patient had pallor.", + "General examination showed well-defined raised lesions over the body.", + "She measured 125 cm in height.", + "She measured 23 kg in weight.", + "The results of the investigation showed neutrophilic leukocytosis.", + "The results showed iron deficiency anemia.", + "The results showed high CRP of 70 mg/dL.", + "The results showed raised ESR of 25 mm at 1 h.", + "Pure tone audiometry revealed right-sided severe mixed hearing loss.", + "Antineutrophilic antibody (ANA), immunoglobulins, and interleukin levels were all within normal limits.", + "Serum amyloid level was high at 295 mg/L.", + "The complaints above of hearing loss, elevated amyloid levels, and inflammatory markers led to the suspicion of Muckle-Wells syndrome.", + "Germline mutations in the NLRP3 gene were detected by Sanger sequencing test.", + "A pediatric rheumatologist advised following up a month after starting Colchicine empirically to prevent amyloidosis.", + "The next plan was to begin Anakinra." + ], + "summary": "We present here an 8-year-old girl with recurrent fever, recurrent urticarial rash, sensorineural hearing loss, raised inflammatory markers and serum amyloid levels, which did not respond to the anti-histaminic drugs, was wrongly diagnosed as tuberculosis, which on further genetic evaluation was diagnosed as MWS.", + "summary_subclaims": [ + "The patient is an 8-year-old girl.", + "The patient had recurrent fever.", + "The patient had recurrent urticarial rash.", + "The patient had sensorineural hearing loss.", + "The patient had raised inflammatory markers.", + "The patient had raised serum amyloid levels.", + "The patient's symptoms did not respond to anti-histaminic drugs.", + "The patient was wrongly diagnosed as tuberculosis.", + "The patient was diagnosed as MWS on further genetic evaluation." + ] + }, + { + "id": "multiclinsum_test_2083_en.txt", + "fulltext": "A 59-year-old woman of sober habits with a 10-year history of poorly controlled Type 2 diabetes, hypertension, and no history of ARF, prior myocarditis, or other known structural heart disease presented with acutely decompensated heart failure. She reported in the past 2 months symptoms of breathlessness, shortness of breath, declining effort tolerance, orthopnoea, bipedal oedema, and paroxysmal nocturnal dyspnoea. Her performance status declined from a NYHA functional Classes II–IV within 3 months.\nPhysical examination revealed no fever, no arthritis, no chorea, no erythema magnatum nor subcutaneous nodules. Further examination showed a normal blood pressure of 140/60 mmHg with a wide pulse pressure, a heart rate of 98 bpm, a collapsing pulse, displaced apical impulse, and elevated jugular venous pressure. Cardiac auscultation showed a normal soft S1, a normal S2, and an S3 gallop. A 3/6 pansystolic murmur in the mitral area, loudest on expiration, was heard, in keeping with MR. She also had a 2/4 early diastolic murmur with arterial findings of severe AR and a widened pulse pressure. The 12-lead ECG showed abnormal QRS wave pattern, repolarization changes, and 1st degree atrioventricular (A-V) block (PR 330 ms) . On chest radiography, there was cardiomegaly, bilateral pleural effusions, upper lobe pulmonary venous diversion in keeping with heart failure, and prominent pulmonary arteries . Transthoracic echocardiography (TTE) with two-dimensional (2D) Doppler imaging showed mildly dilated LV size and normal LV function (LV dimension in diastole (d) 54 mm, and LVEF 60%). The echocardiographic assessment of the right ventricle (RV) and the pulmonary valve showed pulmonary hypertension with normal sized RV with normal RV function and normal pulmonary valve with mild tricuspid regurgitation (TR − TR Vmax 3.66 m/s, TR Pmax 54 mmHg, right atrial (RA) pressure 20 mmHg, RV systolic pressure 74 mmHg, RA area 19.7 cm2). Further, left atrial assessment showed a mildly dilated left atrium (43 mm). Preoperative TTE showed a tri-leaflet AV with calcified lesions on the non-coronary cusps (NCC), and severe AR. Transthoracic echocardiography of MV showed thickened leaflet tips with severe MR ( and ). Coronary angiography showed unobstructed epicardial coronary vessels and confirmed severe AR and MR. Laboratory examination showed elevated CRP 9 mg/dL, and normal white blood cells 7.62 × 109/L. Anti-DNAse B and anti-steptolysin O-titres were not performed. Blood cultures were performed but the bacterial growth had not occurred by the time the patient underwent valve replacement surgery. Microbiology tests for gram-negative bacteria were negative and polymerase chain reaction testing for common bacteria was also negative.\nThe patient was diagnosed with valvular heart disease of probable rheumatic aetiology and with severe AR and MR complicated by heart failure. She was started on heart failure pharmacotherapy and referred for double valve replacement surgery. On-table, transoesophageal echocardiography was performed and showed a large vegetation on the anterior MV leaflet, and another on the NCC of the AV. In addition, Grade III diastolic dysfunction was noted, a large pleural effusion on the right was also seen. She underwent open-heart surgery and had AV and MV replacement, both with bioprosthetic tissue valves, based on patient’s preference. During the operation, it was evident that below the AV there was small root abscess and vegetation on the AV and MV, confirming chronic infective endocarditis. The patient was treated for culture-negative infective endocarditis. The patient was started on an antibiotic therapy (penicillin G 5 million Unit IV 6 hourly for 4 weeks, gentamycin 80 mg IV three times a day for 2 weeks, doxycycline 100 milligrams orally twice a day for 4 weeks), discharged home well, and has been doing well on follow-up visits. Her post-surgical course was uneventful.\nThe histopathological assessment showed features of concomitant ARF in a background of chronic RHD. The MV showed evidence of a chronic RHD, with moderate-to-severe fibrosis of the valves, scattered stromal histiocytes, and foci of neovascularization with characteristic thick-walled vessels . The AV showed chronic RHD with stromal neovascularization, fibrosis, and chronic inflammation. Additionally, discrete foci of acute rheumatic valvulitis were evident, with Aschoff bodies containing Anitschkow cells and central fibrinoid necrosis .", + "fulltext_subclaims": [ + "The patient is a 59-year-old woman.", + "She has a 10-year history of poorly controlled Type 2 diabetes.", + "She has hypertension.", + "She has no history of ARF.", + "She has no history of prior myocarditis.", + "She has no known structural heart disease.", + "She presented with acutely decompensated heart failure.", + "She reported breathlessness in the past 2 months.", + "She reported shortness of breath in the past 2 months.", + "She reported declining effort tolerance in the past 2 months.", + "She reported orthopnoea in the past 2 months.", + "She reported bipedal oedema in the past 2 months.", + "She reported paroxysmal nocturnal dyspnoea in the past 2 months.", + "Her performance status declined from NYHA functional Classes II–IV within 3 months.", + "Physical examination showed a normal blood pressure of 140/60 mmHg.", + "Physical examination showed a wide pulse pressure.", + "Physical examination showed a heart rate of 98 bpm.", + "Physical examination showed a collapsing pulse.", + "Physical examination showed an elevated jugular venous pressure.", + "Cardiac auscultation showed an S3 gallop.", + "A 3/6 pansystolic murmur in the mitral area was heard.", + "The murmur was loudest on expiration.", + "The murmur was in keeping with MR.", + "A 2/4 early diastolic murmur was heard.", + "The murmur was in keeping with severe AR.", + "The 12-lead ECG showed a 1st degree atrioventricular (A-V) block.", + "The PR interval was 330 ms.", + "Chest radiography showed cardiomegaly.", + "Chest radiography showed bilateral pleural effusions.", + "Chest radiography showed upper lobe pulmonary venous diversion.", + "Chest radiography showed prominent pulmonary arteries.", + "Transthoracic echocardiography showed mildly dilated LV size.", + "Transthoracic echocardiography showed normal LV function.", + "The LV dimension in diastole was 54 mm.", + "The LVEF was 60%.", + "The right ventricle was normal sized.", + "The right ventricular function was normal.", + "The pulmonary valve was normal.", + "There was mild tricuspid regurgitation.", + "The TR Vmax was 3.66 m/s.", + "The TR Pmax was 54 mmHg.", + "The right atrial pressure was 20 mmHg.", + "The RV systolic pressure was 74 mmHg.", + "The right atrial area was 19.7 cm2.", + "The left atrium was mildly dilated.", + "The left atrial dimension was 43 mm.", + "Preoperative TTE showed a tri-leaflet AV.", + "The AV had calcified lesions on the non-coronary cusps.", + "The AV had severe AR.", + "Transthoracic echocardiography of the MV showed thickened leaflet tips.", + "The MV had severe MR.", + "Coronary angiography showed unobstructed epicardial coronary vessels.", + "Coronary angiography confirmed severe AR.", + "Coronary angiography confirmed severe MR.", + "Laboratory examination showed elevated CRP 9 mg/dL.", + "White blood cells were 7.62 × 109/L.", + "Anti-DNAse B and anti-steptolysin O-titres were not performed.", + "Blood cultures were performed.", + "Bacterial growth had not occurred by the time of surgery.", + "Microbiology tests for gram-negative bacteria were negative.", + "Polymerase chain reaction testing for common bacteria was also negative.", + "The patient was diagnosed with valvular heart disease of probable rheumatic aetiology.", + "She was diagnosed with severe AR.", + "She was diagnosed with severe MR.", + "She was diagnosed with heart failure.", + "She was started on heart failure pharmacotherapy.", + "She was referred for double valve replacement surgery.", + "On-table transoesophageal echocardiography showed a large vegetation on the anterior MV leaflet.", + "On-table transoesophageal echocardiography showed a large vegetation on the NCC of the AV.", + "Grade III diastolic dysfunction was noted.", + "A large pleural effusion on the right was seen.", + "She underwent open-heart surgery.", + "She had AV and MV replacement.", + "Both valves were replaced with bioprosthetic tissue valves.", + "The decision was based on the patient’s preference.", + "During the operation, a small root abscess was evident below the AV.", + "Vegetation on the AV and MV was confirmed.", + "The diagnosis of chronic infective endocarditis was confirmed.", + "The patient was treated for culture-negative infective endocarditis.", + "She was started on penicillin G 5 million Unit IV 6 hourly for 4 weeks.", + "She was started on gentamycin 80 mg IV three times a day for 2 weeks.", + "She was started on doxycycline 100 milligrams orally twice a day for 4 weeks.", + "The patient was discharged home well.", + "The patient has been doing well on follow-up visits.", + "The histopathological assessment showed features of concomitant ARF.", + "The histopathological assessment showed a background of chronic RHD.", + "The MV showed evidence of chronic RHD.", + "The MV showed moderate-to-severe fibrosis of the valves.", + "The MV showed scattered stromal histiocytes.", + "The MV showed foci of neovascularization with characteristic thick-walled vessels.", + "The AV showed chronic RHD.", + "The AV showed stromal neovascularization.", + "The AV showed fibrosis.", + "The AV showed chronic inflammation.", + "Discrete foci of acute rheumatic valvulitis were evident.", + "Aschoff bodies containing Anitschkow cells were present.", + "Central fibrinoid necrosis was present." + ], + "summary": "Here we report on a case of a 59-year-old woman with mixed aortic and mitral valve disease of probable rheumatic aetiology (elevated C-reactive protein and prolonged PR interval) and with histological evidence of lymphocytic infiltration, Aschoff bodies, and fibrinoid necrosis admixed with features of chronic RHD.", + "summary_subclaims": [ + "The patient is a 59-year-old woman.", + "The patient has mixed aortic and mitral valve disease.", + "The aortic and mitral valve disease is of probable rheumatic aetiology.", + "The patient has elevated C-reactive protein.", + "The patient has a prolonged PR interval.", + "There is histological evidence of lymphocytic infiltration.", + "There is histological evidence of Aschoff bodies.", + "There is histological evidence of fibrinoid necrosis.", + "The histology shows features of chronic rheumatic heart disease." + ] + }, + { + "id": "multiclinsum_test_1908_en.txt", + "fulltext": "A multigravid 31-year-old white woman and her 35-year-old white husband were admitted for pre-pregnancy consulting for their fourth pregnancy. In their first pregnancy, no fetal movement was detected by sonography at the 18th gestational week. Subsequently, three-dimensional ultrasound imaging showed a fetus with cystic kidneys and fusion of the lower limbs, so the pregnancy was terminated by induced abortion. The woman later gave birth to a normal baby at gravida 2, but at 32 weeks of her gravida 3, vaginal delivery following intrauterine fetal death (IUFD) occurred. The physical examination of the stillborn baby showed typical Potter facies and normal upper part of the body with fused lower limbs and two feet. The two feet were fused, and the femur and tibiae with four toes were discriminable. The external genitalia and anal opening were absent, as shown in Fig. . Although the exact type of anomaly cannot be identified in the absence of radiographic findings, it may be classified as type II or III based on the Stocker and Heifetz classification, since the fusion somewhat affects superficial tissue. There was no report of diabetes mellitus (DM) or other anomalies in the mother’s medical history or familial medical history. Moreover, their marriage was non-consanguineous, and the mother had not had exposure to any intrinsic or extrinsic factors (such as teratogenic drug intake) associated with sirenomelia during her pregnancy. Further investigation could not be conducted because the parents refused autopsy.\nEventually, the follow-up to her fourth pregnancy indicated that she gave birth to a normal baby.", + "fulltext_subclaims": [ + "A multigravid 31-year-old white woman and her 35-year-old white husband were admitted for pre-pregnancy consulting for their fourth pregnancy.", + "In their first pregnancy, no fetal movement was detected by sonography at the 18th gestational week.", + "Three-dimensional ultrasound imaging showed a fetus with cystic kidneys and fusion of the lower limbs.", + "The pregnancy was terminated by induced abortion.", + "The woman later gave birth to a normal baby at gravida 2.", + "At 32 weeks of her gravida 3, vaginal delivery following intrauterine fetal death (IUFD) occurred.", + "The physical examination of the stillborn baby showed typical Potter facies.", + "The external genitalia and anal opening were absent.", + "The exact type of anomaly cannot be identified in the absence of radiographic findings.", + "It may be classified as type II or III based on the Stocker and Heifetz classification.", + "There was no report of diabetes mellitus (DM) or other anomalies in the mother’s medical history.", + "Their marriage was non-consanguineous.", + "The mother had not had exposure to any intrinsic or extrinsic factors associated with sirenomelia during her pregnancy.", + "Further investigation could not be conducted because the parents refused autopsy.", + "Eventually, the follow-up to her fourth pregnancy indicated that she gave birth to a normal baby." + ], + "summary": "We report two white cases of sirenomelia occurring in a 31-year-old multigravid pregnant woman. In the first pregnancy (18 weeks of gestation) abortion was performed, but in the third pregnancy (32 weeks) the stillborn baby was delivered by spontaneous vaginal birth. In the second and fourth pregnancies, however, she gave birth to normal babies. Three-dimensional ultrasound imaging showed fusion of the lower limbs. Neither she nor any member of her family had a history of diabetes. In terms of other risk factors, she had no history of exposure to teratogenic agents during her pregnancy. Also, her marriage was non-consanguineous.", + "summary_subclaims": [ + "The patient is a 31-year-old multigravid pregnant woman.", + "The first pregnancy was at 18 weeks of gestation.", + "Abortion was performed in the first pregnancy.", + "The third pregnancy was at 32 weeks of gestation.", + "The stillborn baby was delivered by spontaneous vaginal birth in the third pregnancy.", + "The second pregnancy resulted in a normal baby.", + "The fourth pregnancy resulted in a normal baby.", + "Three-dimensional ultrasound imaging showed fusion of the lower limbs.", + "The patient had no history of diabetes.", + "The patient had no history of exposure to teratogenic agents during her pregnancy.", + "The patient's marriage was non-consanguineous." + ] + }, + { + "id": "multiclinsum_test_921_en.txt", + "fulltext": "A 5-year-old boy presented with headache, vomiting, and vertigo with a duration of 5 months. CT and MRI examinations revealed the presence of a right cerebellar mass with mild enhancement and of a right temporal mass with moderate enhancement . The tumors were hypointensive in T1-weighted MRI scans and hyperintensive in T2-weighted MRI scans. CT examination revealed that both tumors were hyperdense. Following these examinations, the patient was referred to our hospital.\nDuring surgery, the two tumors were observed to have similar appearances. Both tumors were reddish-colored and soft, had a moderate blood supply, and were easy to suction. The postsurgical pathology reports stated that the tumors were a DMB (cerebellar mass) and PNET (temporal mass) .\nDue to the suspicion that the boy had GS, he was evaluated for this condition. The circumference of his head was 48 cm. Physical examination revealed the presence of multiple café-au-lait spots . Plain film X-ray imaging demonstrated the presence of a bifid rib and a jaw cyst . The PTCH1 gene test was negative. We conducted a molecular classification of the cerebellar tumor using the real-time polymerase chain reaction (PCR) method and the NanoString method and discovered that the DMB was a SHH subtype tumor. Based on two major and one minor criteria for GS (desmoplastic MB, bifid rib, and jaw cyst, respectively), an unambiguous diagnosis of GS was made.\nAfter the patient was discharged, his parents refused to allow him to receive chemotherapy, which is a treatment that must be covered by out-of-pocket payments in China, due to their financial difficulties. The patient instead underwent 30.6-Gy irradiation of the entire brain and the spinal axis and 54-Gy irradiation of the posterior fossa. At follow-up, an MRI examination showed no tumor recurrence. Twenty-seven months after receiving radiotherapy, the patient experienced chest pain and had a fever. CT examinations revealed the presence of a mediastinal mass and chest effusion . Analysis of a biopsy performed at another hospital demonstrated that the mass was T cell non-Hodgkin’s lymphoma . The patient’s parent refused treatment because of financial difficulties, and the boy died 1 month later.\nDMB and medulloblastoma with extensive nodularity (MBEN) are closely associated with GS. The development of DMB and MBEN, which are generally the first tumoral manifestations in patients with GS, is thought to be the major criterion for the diagnosis . The prevalence of MB in GS patients in early childhood is difficult to estimate. The incidence of GS in MB patients was reported to be 1–2 %, and 3–5 % of GS patients develop medulloblastoma, generally within the first 2 years of life . In a retrospective investigation, 5 of 82 medulloblastoma patients were diagnosed with GS . In Amlashi’s cohort of 76 MB patients, the incidence of GS among the entire cohort was 4 %, the incidence of GS in patients younger than 5 years old was 10.7 %, and the incidence of GS in patients younger than 2 years old was 25 % . In a Japanese survey, 3.3 % of 157 GS patients had MB .\nTo the best of our knowledge, this is the first report of a concurrent infratentorial medulloblastoma and a supratentorial PNET in a GS patient. On cerebrospinal axis MRI examination, there were no signs of CSF seeding; two images appeared different under microscope examination, which excluded the occurrence of tumor metastasis. The molecular classification of the DMB as a SHH subtype tumor was also consistent with the diagnosis of GS. Our patient could have been diagnosed with GS based on the presence of DMB, a PNET, a jaw cyst, a bifid rib, and multiple café-au-lait spots, as well as the classification of the DMB as a SHH subtype tumor. The occurrence of multiple café-au-lait spots is associated with many hereditary disease, including neurofibromatosis type 1, McCune-Albright syndrome, Cowden syndrome, and LEOPARD syndrome . This is the fourth case report of multiple café-au-lait spots in a GS patient [, ]. Because the clinical diagnostic criteria for GS are continually changing, we propose that the presence of café-au-lait spots in young DMB patients should be considered a “trigger” for ordering a diagnostic evaluation and a molecular blood test for GS.\nGS patients are at a high risk of developing multiple BCCs and other radiation-induced tumors, such as meningioma, ependymoma, and fibrosarcoma, in irradiated areas. To date, this is the first report of the development of post-treatment non-Hodgkin’s lymphoma in a GS patient. The hedgehog pathway regulates intrathymic T cell development. Aberrant activation of the hedgehog pathway is associated with the pathogenesis of malignant lymphoma . Irradiation induces DNA damage and genomic instability in circulating and thymic lymphocytes, which results in apoptosis, abnormal DNA methylation, and changes in RNA expression [, ]. Our patient developed mediastinal lymphoma, which was unequivocally diagnosed as a radiation-induced tumor. Interestingly, we found one report of a radiation-induced PNET that developed following treatment for non-Hodgkin’s lymphoma . These findings may facilitate elucidation of the molecular mechanisms underlying tumorigenesis in GS patients.\nEarly and prompt diagnosis is important in patients suspected to have GS, as chemotherapy is the first-line treatment for tumors in GS patients. The desmoplastic variant of MB and MBEN in GS generally occur in children who are 2 years of age or younger. Most of the main criteria for GS, such as intracranial calcification, jaw cysts, and BCC, do not appear until the second decade of life, which makes early diagnosis of GS in very young patients difficult . Medulloblastoma patients with GS generally have a promising survival rate due to recent advancements made in chemotherapy . The detection rate of a mutated PTCH 1 gene is only 50–85 % , which makes early diagnosis more difficult. Amlashi et al. have even suggested avoiding radiotherapy in DMB patients who are less than 5 years old .\nThe overexpression of the members of the canonical hedgehog signaling pathway plays an important role in tumorigenesis in GS patients. In the majority of GS patients, the loss of function of PTCH1 has been found, which causes the reduction of the inhibition of the smoothened (SMO) oncogene and the subsequent aberrant activation of the glioma-associated oncogene homolog (GLI) family members. It is possible that SMO inhibitors, such as vismodegib, may serve as new therapeutics for the treatment of tumors in GS patients. Vismodegib has proven to be effective in the treatment of GS-related BCC and keratocystic odontogenic tumors [, ]. Robinson et al. reported that vismodegib exhibited activity against adult recurrent or refractory SHH-MB . However, the response to SMO inhibitors of medulloblastoma patients was variable and transient, and this drug was most effective in treating tumors with upstream activating aberrations in the SHH pathway. The existence of a PTCH1 mutation was correlated with a positive response to the drug, and aberrations in GIL2 and SUFU were found in the nonresponders .\nThe lack of efficacy of SMO inhibitors and the acquired resistance to these inhibitors in medulloblastoma patients argues for the use of GLI-specific inhibitors. GLI1 is the most significant member of the hedgehog pathway and plays a role in promoting carcinogenesis. Several studies have shown that aberrant GLI1 expression occurred independently from the signaling of the canonical HH pathway through PTCH and SMO [, ] and was responsible for the development of radioresistance and chemoresistance in tumors . The aberrant expression of GLI1 was closely linked to the activity of several non-canonical signaling pathways, such as the Kirsten rat sarcoma viral oncogene homolog (KRAS) pathway, the avian myelocytomatosis virus oncogene cellular homolog (C-MYC) pathway, the transforming growth factor β (TGFβ) pathway, the wingless-type MMTV integration site family (WNT) pathway, and the β-catenin pathway. Together, these data suggest that administering specific inhibitors of the final step in the hedgehog pathway may be the most effective treatment option and the ideal approach to use in future studies. Currently, there are several agents (HPT, GANT58, GANT61, and arsenic trioxide) that are known to inhibit the transcriptional activity of GLI [, ]. Although GLI1-specific inhibitors are still in the preclinical stage of testing, studies in which combinations of GLI1 inhibitors and chemotherapeutic agents were used to treat other types of tumors have been conducted .", + "fulltext_subclaims": [ + "A 5-year-old boy presented with headache, vomiting, and vertigo with a duration of 5 months.", + "CT and MRI examinations revealed the presence of a right cerebellar mass with mild enhancement and of a right temporal mass with moderate enhancement.", + "The tumors were hypointensive in T1-weighted MRI scans and hyperintensive in T2-weighted MRI scans.", + "CT examination revealed that both tumors were hyperdense.", + "Following these examinations, the patient was referred to our hospital.", + "During surgery, the two tumors were observed to have similar appearances.", + "Both tumors were reddish-colored and soft, had a moderate blood supply, and were easy to suction.", + "The postsurgical pathology reports stated that the tumors were a DMB (cerebellar mass) and PNET (temporal mass).", + "Due to the suspicion that the boy had GS, he was evaluated for this condition.", + "The circumference of his head was 48 cm.", + "Physical examination revealed the presence of multiple café-au-lait spots.", + "Plain film X-ray imaging demonstrated the presence of a bifid rib and a jaw cyst.", + "The PTCH1 gene test was negative.", + "We conducted a molecular classification of the cerebellar tumor using the real-time polymerase chain reaction (PCR) method and the NanoString method.", + "We discovered that the DMB was a SHH subtype tumor.", + "Based on two major and one minor criteria for GS (desmoplastic MB, bifid rib, and jaw cyst, respectively), an unambiguous diagnosis of GS was made.", + "After the patient was discharged, his parents refused to allow him to receive chemotherapy.", + "The patient instead underwent 30.6-Gy irradiation of the entire brain and the spinal axis and 54-Gy irradiation of the posterior fossa.", + "At follow-up, an MRI examination showed no tumor recurrence.", + "Twenty-seven months after receiving radiotherapy, the patient experienced chest pain and had a fever.", + "CT examinations revealed the presence of a mediastinal mass and chest effusion.", + "Analysis of a biopsy performed at another hospital demonstrated that the mass was T cell non-Hodgkin’s lymphoma.", + "The patient’s parent refused treatment because of financial difficulties.", + "The boy died 1 month later.", + "DMB and medulloblastoma with extensive nodularity (MBEN) are closely associated with GS.", + "The development of DMB and MBEN, which are generally the first tumoral manifestations in patients with GS, is thought to be the major criterion for the diagnosis.", + "The incidence of GS in MB patients was reported to be 1–2 %.", + "3–5 % of GS patients develop medulloblastoma, generally within the first 2 years of life.", + "In a retrospective investigation, 5 of 82 medulloblastoma patients were diagnosed with GS.", + "In Amlashi’s cohort of 76 MB patients, the incidence of GS among the entire cohort was 4 %.", + "The incidence of GS in patients younger than 5 years old was 10.7 %.", + "The incidence of GS in patients younger than 2 years old was 25 %.", + "In a Japanese survey, 3.3 % of 157 GS patients had MB.", + "To the best of our knowledge, this is the first report of a concurrent infratentorial medulloblastoma and a supratentorial PNET in a GS patient.", + "On cerebrospinal axis MRI examination, there were no signs of CSF seeding.", + "Two images appeared different under microscope examination, which excluded the occurrence of tumor metastasis.", + "The molecular classification of the DMB as a SHH subtype tumor was also consistent with the diagnosis of GS.", + "Our patient could have been diagnosed with GS based on the presence of DMB, a PNET, a jaw cyst, a bifid rib, and multiple café-au-lait spots, as well as the classification of the DMB as a SHH subtype tumor.", + "The occurrence of multiple café-au-lait spots is associated with many hereditary diseases, including neurofibromatosis type 1, McCune-Albright syndrome, Cowden syndrome, and LEOPARD syndrome.", + "This is the fourth case report of multiple café-au-lait spots in a GS patient.", + "Because the clinical diagnostic criteria for GS are continually changing, we propose that the presence of café-au-lait spots in young DMB patients should be considered a 'trigger' for ordering a diagnostic evaluation and a molecular blood test for GS.", + "GS patients are at a high risk of developing multiple BCCs and other radiation-induced tumors, such as meningioma, ependymoma, and fibrosarcoma, in irradiated areas.", + "To date, this is the first report of the development of post-treatment non-Hodgkin’s lymphoma in a GS patient.", + "The hedgehog pathway regulates intrathymic T cell development.", + "Aberrant activation of the hedgehog pathway is associated with the pathogenesis of malignant lymphoma.", + "Irradiation induces DNA damage and genomic instability in circulating and thymic lymphocytes, which results in apoptosis, abnormal DNA methylation, and changes in RNA expression.", + "Our patient developed mediastinal lymphoma, which was unequivocally diagnosed as a radiation-induced tumor.", + "We found one report of a radiation-induced PNET that developed following treatment for non-Hodgkin’s lymphoma.", + "Early and prompt diagnosis is important in patients suspected to have GS, as chemotherapy is the first-line treatment for tumors in GS patients.", + "The desmoplastic variant of MB and MBEN in GS generally occur in children who are 2 years of age or younger.", + "Most of the main criteria for GS, such as intracranial calcification, jaw cysts, and BCC, do not appear until the second decade of life, which makes early diagnosis of GS in very young patients difficult.", + "Medulloblastoma patients with GS generally have a promising survival rate due to recent advancements made in chemotherapy.", + "The detection rate of a mutated PTCH 1 gene is only 50–85 %, which makes early diagnosis more difficult.", + "Amlashi et al. have even suggested avoiding radiotherapy in DMB patients who are less than 5 years old.", + "The overexpression of the members of the canonical hedgehog signaling pathway plays an important role in tumorigenesis in GS patients.", + "In the majority of GS patients, the loss of function of PTCH1 has been found, which causes the reduction of the inhibition of the smoothened (SMO) oncogene and the subsequent aberrant activation of the glioma-associated oncogene homolog (GLI) family members.", + "It is possible that SMO inhibitors, such as vismodegib, may serve as new therapeutics for the treatment of tumors in GS patients.", + "Vismodegib has proven to be effective in the treatment of GS-related BCC and keratocystic odontogenic tumors.", + "Robinson et al. reported that vismodegib exhibited activity against adult recurrent or refractory SHH-MB.", + "The response to SMO inhibitors of medulloblastoma patients was variable and transient, and this drug was most effective in treating tumors with upstream activating aberrations in the SHH pathway.", + "The existence of a PTCH1 mutation was correlated with a positive response to the drug, and aberrations in GIL2 and SUFU were found in the nonresponders.", + "The lack of efficacy of SMO inhibitors and the acquired resistance to these inhibitors in medulloblastoma patients argues for the use of GLI-specific inhibitors.", + "GLI1 is the most significant member of the hedgehog pathway and plays a role in promoting carcinogenesis.", + "Several studies have shown that aberrant GLI1 expression occurred independently from the signaling of the canonical HH pathway through PTCH and SMO.", + "The aberrant expression of GLI1 was closely linked to the activity of several non-canonical signaling pathways, such as the Kirsten rat sarcoma viral oncogene homolog (KRAS) pathway, the avian myelocytomatosis virus oncogene cellular homolog (C-MYC) pathway, the transforming growth factor β (TGFβ) pathway, the wingless-type MMTV integration site family (WNT) pathway, and the β-catenin pathway.", + "Together, these data suggest that administering specific inhibitors of the final step in the hedgehog pathway may be the most effective treatment option and the ideal approach to use in future studies.", + "Currently, there are several agents (HPT, GANT58, GANT61, and arsenic trioxide) that are known to inhibit the transcriptional activity of GLI.", + "Although GLI1-specific inhibitors are still in the preclinical stage of testing, studies in which combinations of GLI1 inhibitors and chemotherapeutic agents were used to treat other types of tumors have been conducted." + ], + "summary": "In the present study, a 5-year-old male patient had a concurrent cerebellar desmoplastic medulloblastoma and temporal primitive neuroectodermal tumor. Examinations of this patient revealed multiple café-au-lait spots, a jaw cyst, and a bifid rib. A molecular classification analysis revealed that the patient's cerebellar tumor was of the sonic hedgehog subtype. Twenty-seven months after tumor resection and cerebrospinal irradiation were performed, mediastinal lymphoma was found in the patient. The patient ultimately died of lymphoma. To the best of our knowledge, this is the first report of a concurrent medulloblastoma and primitive neuroectodermal tumor and the fourth report of multiple café-au-lait spots in a patient with Gorlin syndrome. This report is also the first account of the development of mediastinal lymphoma after spinal irradiation in a patient with Gorlin syndrome.", + "summary_subclaims": [ + "A 5-year-old male patient had a concurrent cerebellar desmoplastic medulloblastoma and temporal primitive neuroectodermal tumor.", + "Examinations of this patient revealed multiple café-au-lait spots.", + "Examinations of this patient revealed a jaw cyst.", + "Examinations of this patient revealed a bifid rib.", + "A molecular classification analysis revealed that the patient's cerebellar tumor was of the sonic hedgehog subtype.", + "Twenty-seven months after tumor resection and cerebrospinal irradiation were performed, mediastinal lymphoma was found in the patient.", + "The patient ultimately died of lymphoma.", + "To the best of our knowledge, this is the first report of a concurrent medulloblastoma and primitive neuroectodermal tumor.", + "This is the fourth report of multiple café-au-lait spots in a patient with Gorlin syndrome.", + "This report is the first account of the development of mediastinal lymphoma after spinal irradiation in a patient with Gorlin syndrome." + ] + }, + { + "id": "multiclinsum_test_395_en.txt", + "fulltext": "A 68-years-old Mongoloid woman presented with an asymptomatic, flesh-colored lesion on the right upper eyelid. The lesion had slowly increased in size over 5 years. No similar lesions were found on other parts of the body. Her medical and family histories were unremarkable, and she had experienced no triggering trauma.\nUpon ophthalmologic examination, the protruding lesion was found to be approximately 5 × 5 × 4 mm and located on the upper lid margin . Palpation of the lesion did not elicit pain, and the lesion was non-slidable. On the photography of anterior segment, the nodule was verified as flesh-colored, dome-shaped, with eyelashes on the smooth surface, and the lesion located on the anterior lamella of the lid margin, without superficial ulceration and dilated blood vessels. . The conjunctiva, cornea, and lens were unremarkable and so as the fundus examination results. Examinations showed that the left eye was normal. The visual acuity of both eyes was 20/20.\nThe lesion was removed by shave excision under local anesthesia. The lesion was non-slidable, and it was adherent to the tarsal plate and its covered skin. Anterior lamella of the eyelid was resected with a trigonal wedge, with the removal of 1 mm of extra tissue from the margin of the lesion, and the thin layer of the tarsal plate. The anterior lamella defect of the upper eyelid was repaired using A-T flap. A gray line split was performed on the cut ends of skin defects, then, the skin defects were sutured directly. We checked the preauricular lymph nodes, and no lymphadenopathy was found. After the operation, the patient was compression bandaged for 24 h.\nHistologically examination of the lesion showed a well-defined tumor mass involving a hair follicle, and a proliferation of multiple thin strands of basaloid cells, extending from the central follicle into the surrounding fibrous stroma. The fibrous stroma presented a sharp contrast with the surrounding dermis. Hematoxylin-eosin stains contained mucin content in the stroma . The histologic findings were characteristic of fibrofolliculoma.\nTwo weeks after the surgery, the patient had no particular complain. The right upper lid showed almost identical to that of the left . During the 3-month follow-up, no signs of recurrence or new lesions appeared.", + "fulltext_subclaims": [ + "The patient is a 68-years-old Mongoloid woman.", + "She presented with an asymptomatic, flesh-colored lesion on the right upper eyelid.", + "The lesion had slowly increased in size over 5 years.", + "No similar lesions were found on other parts of the body.", + "Her medical and family histories were unremarkable.", + "She had experienced no triggering trauma.", + "The protruding lesion was approximately 5 × 5 × 4 mm and located on the upper lid margin.", + "Palpation of the lesion did not elicit pain.", + "The lesion was non-slidable.", + "On the photography of anterior segment, the nodule was verified as flesh-colored, dome-shaped, with eyelashes on the smooth surface.", + "The lesion was located on the anterior lamella of the lid margin.", + "There was no superficial ulceration.", + "There were no dilated blood vessels.", + "The conjunctiva, cornea, and lens were unremarkable.", + "The fundus examination results were unremarkable.", + "The left eye was normal.", + "The visual acuity of both eyes was 20/20.", + "The lesion was removed by shave excision under local anesthesia.", + "The lesion was adherent to the tarsal plate and its covered skin.", + "Anterior lamella of the eyelid was resected with a trigonal wedge.", + "The anterior lamella defect of the upper eyelid was repaired using A-T flap.", + "A gray line split was performed on the cut ends of skin defects.", + "The skin defects were sutured directly.", + "We checked the preauricular lymph nodes.", + "No lymphadenopathy was found.", + "After the operation, the patient was compression bandaged for 24 h.", + "Histologically examination of the lesion showed a well-defined tumor mass involving a hair follicle.", + "The histologic findings were characteristic of fibrofolliculoma.", + "Two weeks after the surgery, the patient had no particular complain.", + "The right upper lid showed almost identical to that of the left.", + "During the 3-month follow-up, no signs of recurrence or new lesions appeared." + ], + "summary": "A 68-year-old female presented with an asymptomatic mass on the right upper eyelid. The lesion appeared as a flesh-colored, dome-shaped, smooth nodule being the size of 5 × 5 × 4 mm, with eyelashes protruding from the surface, and located on the upper lid margin. Shave excision was performed, and the diagnosis of fibrofolliculoma was confirmed finally through histological exam.", + "summary_subclaims": [ + "The patient is a 68-year-old female.", + "The patient had an asymptomatic mass on the right upper eyelid.", + "The lesion was flesh-colored.", + "The lesion was dome-shaped.", + "The lesion was smooth.", + "The lesion was the size of 5 × 5 × 4 mm.", + "Eyelashes protruded from the surface of the lesion.", + "The lesion was located on the upper lid margin.", + "Shave excision was performed.", + "The diagnosis of fibrofolliculoma was confirmed finally through histological exam." + ] + }, + { + "id": "multiclinsum_test_1897_en.txt", + "fulltext": "A 20-year-old man presented to the emergency department after four days of progressively worsening periumbilical pain. He was moving heavy boxes for his job when he began experiencing pain and was unable to finish his work. He reported pain with defecation but denied fever, chills, nausea, emesis, weight loss, and recent travel or illness. Past surgical history included branchial cleft cyst excision as a child. On abdominal exam, a one square-centimeter erythematous infra-umbilical mass was exquisitely tender to palpation. Laboratory data on admission demonstrated a WBC count of 10.7 × 103 cells/μL and urinalysis was unremarkable. Based on history and physical exam, the patient underwent diagnostic evaluation for suspected incarcerated umbilical hernia.\nCT abdomen/pelvis revealed a four-centimeter segment of organized periumbilical inflammation with central lucency passing the ventral abdominal wall into the anterior abdominal compartment . The process was extraperitoneal and there was no evidence of communication with the urinary bladder. These findings were consistent with an inflamed urachal remnant complicated by abscess. Our patient received intravenous antibiotics in preparation for an operation. The following day he underwent abscess incision and drainage followed immediately by urachal cyst excision through a four-centimeter infra-umbilical midline mini-laparotomy. The urachal cyst and remnants were dissected inferiorly to confirm no communication with the urinary bladder before total excision (A). Investigation of the cyst contents revealed white sebaceous material (B). Pathology examined the 4 × 3 x 0.7-centimeter segment of fibromembranous tissue and confirmed intraoperative impressions of the specimen .\nThe patient was admitted to the surgical floor where he noted his pain was markedly improved. The next day he was discharged to home on post-operative day two with adequate pain control. Two-week follow up in the outpatient surgery clinic confirmed an uncomplicated recovery.", + "fulltext_subclaims": [ + "A 20-year-old man presented to the emergency department after four days of progressively worsening periumbilical pain.", + "He was moving heavy boxes for his job when he began experiencing pain.", + "He reported pain with defecation.", + "He denied fever, chills, nausea, emesis, weight loss, and recent travel or illness.", + "Past surgical history included branchial cleft cyst excision as a child.", + "On abdominal exam, a one square-centimeter erythematous infra-umbilical mass was exquisitely tender to palpation.", + "Laboratory data on admission demonstrated a WBC count of 10.7 × 103 cells/μL.", + "Urinalysis was unremarkable.", + "The patient underwent diagnostic evaluation for suspected incarcerated umbilical hernia.", + "CT abdomen/pelvis revealed a four-centimeter segment of organized periumbilical inflammation with central lucency passing the ventral abdominal wall into the anterior abdominal compartment.", + "The process was extraperitoneal.", + "There was no evidence of communication with the urinary bladder.", + "These findings were consistent with an inflamed urachal remnant complicated by abscess.", + "The patient received intravenous antibiotics in preparation for an operation.", + "The patient underwent abscess incision and drainage followed immediately by urachal cyst excision through a four-centimeter infra-umbilical midline mini-laparotomy.", + "The urachal cyst and remnants were dissected inferiorly to confirm no communication with the urinary bladder before total excision.", + "Investigation of the cyst contents revealed white sebaceous material.", + "Pathology examined the 4 × 3 x 0.7-centimeter segment of fibromembranous tissue.", + "Pathology confirmed intraoperative impressions of the specimen.", + "The patient was admitted to the surgical floor.", + "The patient noted his pain was markedly improved.", + "The patient was discharged to home on post-operative day two with adequate pain control.", + "Two-week follow up in the outpatient surgery clinic confirmed an uncomplicated recovery." + ], + "summary": "A 20-year-old man presented with periumbilical pain. Physical exam showed a warm, erythematous infra-umbilical mass that was tender to palpation. CT revealed an infected urachal cyst. The patient underwent urachal abscess incision and drainage with cyst excision. The patient returned home on postoperative day two. Two-week outpatient follow-up confirmed an uncomplicated recovery.", + "summary_subclaims": [ + "The patient is a 20-year-old man.", + "The patient presented with periumbilical pain.", + "Physical exam showed a warm, erythematous infra-umbilical mass.", + "The mass was tender to palpation.", + "CT revealed an infected urachal cyst.", + "The patient underwent urachal abscess incision and drainage.", + "The patient underwent cyst excision.", + "The patient returned home on postoperative day two.", + "Two-week outpatient follow-up confirmed an uncomplicated recovery." + ] + }, + { + "id": "multiclinsum_test_2606_en.txt", + "fulltext": "A 23-year-old primigravida Asian woman was referred at 33 weeks of gestation for several abnormal ultrasound findings, including small gastric bubble, talipes equinovarus, and polyhydramnios. On the first visit, the estimated fetal body weight was 1627 g (−1.5 SD), and the amniotic fluid index was 30.7 cm. The fetus had macroglossia, talipes equinovarus, and levocardia without cardiac structural abnormalities. The parents had no physical features and reported no past or family history. The mothers of the parents also had no history of miscarriages.\nThe result of G-banding by amniocentesis performed at 32 weeks revealed a marker chromosome . Fluorescence in situ hybridization (FISH) was performed to examine the origin of the chromosome using whole chromosome painting (WCP) and nucleolus organizer region (NOR) probes. Both WCP5 and NOR were positive; therefore, the marker chromosome was determined to be derived from chromosome 5 and an acrocentric chromosome. From the G-banding findings, the derived region of chromosome 5 was pter→p13, and the karyotype was diagnosed as 47, XY, +mar. ish +mar(WCP5+), which included the critical region of 5p13 duplication syndrome. Array comparative genomic hybridization should be done to further confirm the origin of the marker chromosome, but consent could not be obtained.\nAmnioreduction was performed three times during the pregnancy, at 35, 38, and 39 weeks of gestation, for symptomatic polyhydramnios. At 39 weeks and 5 days, a 2462 g male infant was delivered after induction of labor. Immediately after birth, remarkable hypotonia was seen, and respiratory care was needed. APGAR scores at 1 and 5 minutes after birth were one and seven points, respectively. The infant’s physical features included enlarged head circumference, saddle nose, posterior neck thickening, low-set ears, macroglossia, cleft of the soft palate, micrognathia, and talipes equinovarus of both feet. After an examination of the infant, hypoplasia of the corpus callosum, atrial septal defect, and hypothyroidism were detected. On postnatal day 1, a mass shadow of the right lower lung field was detected through a chest X-ray . Computed tomography was performed to confirm the mass and revealed a bilateral CDH . At 5 months after birth, deterioration of the respiratory condition due to laryngomalacia was managed by tracheotomy. At 8 months, cardioplasty and gastrostomy were performed for impaired swallowing function. During the operation, a defect was identified in the muscle of the medial-ventral diaphragm, and a membranous sac was formed in the right thorax. The liver and right adrenal gland were herniated into the right thorax, which may have caused the levocardia. However, only a medial muscle defect without herniation of organs was detected in the left side diaphragm. The bilateral pulmonary hypoplasia was mild, and the hernia sac simultaneously closed. At 10 months, the patient was discharged and transferred to a care hospital. The patient died of aspiration pneumonia and paralytic ileus at 17 months of age.\nThe postnatal karyotyping of peripheral blood was the same as that of prenatal karyotyping. Examination of their karyotype, especially regarding the presence of balanced reciprocal translocations, was offered to the parents. However, they declined the karyotyping examination.", + "fulltext_subclaims": [ + "A 23-year-old primigravida Asian woman was referred at 33 weeks of gestation.", + "Abnormal ultrasound findings included small gastric bubble, talipes equinovarus, and polyhydramnios.", + "The estimated fetal body weight was 1627 g (−1.5 SD).", + "The amniotic fluid index was 30.7 cm.", + "The fetus had macroglossia.", + "The fetus had talipes equinovarus.", + "The fetus had levocardia.", + "The fetus had no cardiac structural abnormalities.", + "The parents had no physical features.", + "The parents reported no past or family history.", + "The mothers of the parents also had no history of miscarriages.", + "G-banding by amniocentesis performed at 32 weeks revealed a marker chromosome.", + "Fluorescence in situ hybridization (FISH) was performed to examine the origin of the chromosome.", + "Whole chromosome painting (WCP) and nucleolus organizer region (NOR) probes were used.", + "Both WCP5 and NOR were positive.", + "The marker chromosome was determined to be derived from chromosome 5 and an acrocentric chromosome.", + "The derived region of chromosome 5 was pter→p13.", + "The karyotype was diagnosed as 47, XY, +mar. ish +mar(WCP5+).", + "Array comparative genomic hybridization should be done to further confirm the origin of the marker chromosome.", + "Consent could not be obtained for array comparative genomic hybridization.", + "Amnioreduction was performed three times during the pregnancy.", + "Amnioreduction was performed at 35, 38, and 39 weeks of gestation.", + "A 2462 g male infant was delivered at 39 weeks and 5 days.", + "The infant had remarkable hypotonia immediately after birth.", + "Respiratory care was needed immediately after birth.", + "APGAR scores at 1 and 5 minutes after birth were one and seven points, respectively.", + "The infant’s physical features included enlarged head circumference.", + "The infant’s physical features included saddle nose.", + "The infant’s physical features included posterior neck thickening.", + "The infant’s physical features included low-set ears.", + "The infant’s physical features included macroglossia.", + "The infant’s physical features included cleft of the soft palate.", + "The infant’s physical features included micrognathia.", + "The infant’s physical features included talipes equinovarus of both feet.", + "Hypoplasia of the corpus callosum was detected.", + "Atrial septal defect was detected.", + "Hypothyroidism was detected.", + "A mass shadow of the right lower lung field was detected through a chest X-ray on postnatal day 1.", + "Computed tomography confirmed the mass and revealed bilateral CDH.", + "At 5 months after birth, deterioration of the respiratory condition due to laryngomalacia was managed by tracheotomy.", + "At 8 months, cardioplasty and gastrostomy were performed.", + "A defect was identified in the muscle of the medial-ventral diaphragm.", + "A membranous sac was formed in the right thorax.", + "The liver and right adrenal gland were herniated into the right thorax.", + "Only a medial muscle defect without herniation of organs was detected in the left side diaphragm.", + "Bilateral pulmonary hypoplasia was mild.", + "The hernia sac simultaneously closed.", + "The patient was discharged at 10 months.", + "The patient was transferred to a care hospital.", + "The patient died of aspiration pneumonia and paralytic ileus at 17 months of age.", + "Postnatal karyotyping of peripheral blood was the same as prenatal karyotyping.", + "Examination of their karyotype, especially regarding the presence of balanced reciprocal translocations, was offered to the parents.", + "The parents declined the karyotyping examination." + ], + "summary": "A 23-year-old primigravida Japanese woman was referred for the following abnormal findings at 33 weeks of gestation: polyhydramnios, macroglossia, talipes equinovarus, and levocardia. A marker chromosome was detected by amniocentesis. Fluorescence in situ hybridization with whole chromosome paint 5 and nucleolus organizer region probes confirmed its origin from chromosome 5 and an acrocentric chromosome. The karyotype of the fetus was diagnosed as 47, XY, +mar. ish +mar(WCP5+). At 39 + 5 weeks, a 2462 g male infant was delivered, with a specific facial configuration. Bilateral CDH, hypoplasia of the corpus callosum, atrial septal defect, and hypothyroidism were also detected in the baby. The karyotype of the peripheral blood was consistent with that of the amniocentesis.", + "summary_subclaims": [ + "The patient is a 23-year-old primigravida Japanese woman.", + "The patient was referred at 33 weeks of gestation.", + "Abnormal findings included polyhydramnios.", + "Abnormal findings included macroglossia.", + "Abnormal findings included talipes equinovarus.", + "Abnormal findings included levocardia.", + "A marker chromosome was detected by amniocentesis.", + "Fluorescence in situ hybridization with whole chromosome paint 5 and nucleolus organizer region probes was performed.", + "The marker chromosome was confirmed to originate from chromosome 5.", + "The marker chromosome was confirmed to originate from an acrocentric chromosome.", + "The fetal karyotype was diagnosed as 47, XY, +mar.", + "The fetal karyotype was diagnosed as ish +mar(WCP5+).", + "A male infant was delivered at 39 + 5 weeks.", + "The infant weighed 2462 g at delivery.", + "The infant had a specific facial configuration.", + "Bilateral CDH was detected in the infant.", + "Hypoplasia of the corpus callosum was detected in the infant.", + "An atrial septal defect was detected in the infant.", + "Hypothyroidism was detected in the infant.", + "The karyotype of the peripheral blood was consistent with that of the amniocentesis." + ] + }, + { + "id": "multiclinsum_test_1250_en.txt", + "fulltext": "A 53-year-old male from Kerala, South India presented with loose stools, which were watery in nature and without blood, three–four episodes per day for 3 weeks. He complained of vague abdominal pain on and off, decreased appetite and weight loss of 3–4 kg over 1 month. He gave no history of associated fever, vomiting, urticarial rashes, or any respiratory symptoms.\nIn addition to having alcohol use disorder, he was a known case of type II diabetes mellitus, hypertension and hyperlipidaemia and was on regular oral medications for the previous 2 years. He also experienced recurrent episodes of stroke, which resulted in a left-sided hemiparesis 2 years previously. He was also diagnosed as having pulmonary tuberculosis (sputum-positive), for which he had been on anti-tubercular therapy (ATT) for the previous 6 months. He denied intravenous (IV) drug abuse or any high-risk sexual behaviour. He was not on steroids or immunosuppressive drugs and gave no history of travel outside the state. He reported consumption of only cooked food and there was no food intolerance. All his family members were reported to be healthy.\nHe was a cattle farmer and worked barefoot on his cattle farm; he also had a shallow pond near to his home where he used to grow freshwater fish for consumption. To his knowledge there was no practice of open field human defecation in the farm area.\nHe was treated symptomatically at primary health care facilities and since there was no relief, he was referred to this tertiary care centre.\nOn clinical examination, he was not febrile and vitals were within normal limits. He had bilateral pitting pedal oedema and macular erythematous rashes over the anterior aspect of both the legs for 2 weeks, which were non-migratory in nature. Systemic examination was normal.\nRoutine blood investigations showed decreased haemoglobin (Hb) 9.6 %, elevated total count (TC) 13 600 cells cumm−1 with differential count (DC), polymorphs 90 %, lymphocyte 6 %, eosinophil 2 % and monocytes 2 %, an erythrocyte sedimentation rate (ESR) of 78 mm h−1, and serum electrolytes showed hypokalaemia (potassium – 2.6 meq l−1). His random blood sugar on admission was elevated (274 mg dl−1). He tested negative for viral markers of human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV). Ultrasonography (USG) of the abdomen showed fatty hepatomegaly with focal lesions in the liver, for which computed tomography (CT) of the abdomen and pelvis with contrast was performed. This showed several hypodense lesions involving segment 5 of the liver with mild hepatomegaly. CT of the lungs showed cavitation in the upper lobes of both lungs. Upper gastrointestinal endoscopy was performed, which was normal. Stool was sent for microscopy and bacteriological culture.\nMacroscopically, the stool was watery, yellowish coloured, with no mucus or blood. Wet preparation revealed numerous motile larvae in the rhabditiform stage, which measured 100–400 µm in length×15–20 µm in width and had a short buccal cavity. There were a few oval shaped eggs, ~50–60×30–35 µm in size, with larvae, suggestive of S. stercoralis. There were no pus cells or red blood cells. Stool microscopy following the formal ether concentration technique did not show any additional findings. Stool microscopy was repeated with freshly collected stool samples on three separate occasions, which also demonstrated motile rhabditiform larvae of S. stercoralis . In addition, agar culture method was performed to visualize the positive trail sign. Nearly 2 g of freshly passed stool was placed on an agar plate. The plate was sealed with tape and then incubated at room temperature for 2 days. The plate was later examined and showed a ‘positive trail sign’, that is, there were tracks present as the bacteria were carried over the agar by the migrating larvae. The agar culture method was to be repeated after therapy, if microscopy of stool did not reveal larvae, as it is a more sensitive test for assessing the elimination of the parasite.\nThe bacteriological culture of stool yielded Aeromonas sobria, which was sensitive to ciprofloxacin, chloramphenicol, tetracycline and cotrimoxazole. Stool occult blood (Hemospot kit, standard guaiac method, Tulip Diagnostics, Goa, India) and toxin (VIDAS difficile toxin A and B, bioMérieux SA) were negative.\nHyperinfection syndrome with disseminated strongyloidiasis, alcoholic liver disease, type 2 diabetes mellitus, hypertension, dyslipidaemia and pulmonary tuberculosis.\nTherapy included blood sugar and electrolyte correction and the patient was empirically started on ciprofloxacin intravenously (IV) along with parenteral fluids and other supportive measures.\nFollowing the stool microscopy report, a stat oral dose of a combination of albendazole 400 mg and ivermectin 6 mg, followed by once daily for 2 days, was given. The patient was continued on ciprofloxacin IV for 4 days. He showed symptomatic improvement by the second day of treatment, his stool became semisolid in consistency and the number of motile larvae in fresh stool showed an appreciable reduction. He was discharged after 4 days on mixtard insulin and oral ciprofloxacin 500 mg twice daily for 3 days.\nThe patient was readmitted on the third day of discharge with complaints of fever and recurrence of diarrhoea. His blood sugar value at the time of readmission was again elevated (210 mg dl−1). His total leucocyte count (TLC) was 12 000 cumm−1, with polymorphs 60 %. His blood was sent for culture and empirical therapy was initiated with injected piperacillin/tazobactam and mixtard insulin. Unfortunately, on day 2 of readmission he expired. was isolated from his blood culture 3 days after his readmission, sensitive to cephalosporins, carbapenems, piperacillin/tazobactam and aminoglycosides, but resistant to ciprofloxacin, which he was discharged on for the infection.", + "fulltext_subclaims": [ + "The patient is a 53-year-old male from Kerala, South India.", + "He had loose, watery stools without blood, three–four episodes per day for 3 weeks.", + "He had vague abdominal pain on and off.", + "He had decreased appetite and weight loss of 3–4 kg over 1 month.", + "He had no history of fever, vomiting, urticarial rashes, or respiratory symptoms.", + "He had alcohol use disorder.", + "He was a known case of type II diabetes mellitus.", + "He had hypertension.", + "He had hyperlipidaemia.", + "He had been on regular oral medications for 2 years.", + "He had recurrent episodes of stroke resulting in left-sided hemiparesis 2 years previously.", + "He had pulmonary tuberculosis (sputum-positive).", + "He had been on anti-tubercular therapy for 6 months.", + "He denied intravenous drug abuse or high-risk sexual behaviour.", + "He was not on steroids or immunosuppressive drugs.", + "He had no history of travel outside the state.", + "He consumed only cooked food.", + "He had no food intolerance.", + "All his family members were reported to be healthy.", + "He was a cattle farmer and worked barefoot on his cattle farm.", + "He had a shallow pond near his home where he grew freshwater fish for consumption.", + "There was no practice of open field human defecation in the farm area.", + "He was treated symptomatically at primary health care facilities.", + "He was referred to a tertiary care centre.", + "On clinical examination, he was not febrile and vitals were within normal limits.", + "He had bilateral pitting pedal oedema.", + "He had macular erythematous rashes over the anterior aspect of both legs for 2 weeks.", + "The rashes were non-migratory in nature.", + "Systemic examination was normal.", + "Routine blood investigations showed decreased haemoglobin (Hb 9.6 %).", + "Total count was 13 600 cells cumm−1.", + "Differential count showed polymorphs 90 %.", + "Differential count showed lymphocytes 6 %.", + "Differential count showed eosinophils 2 %.", + "Differential count showed monocytes 2 %.", + "Erythrocyte sedimentation rate was 78 mm h−1.", + "Serum electrolytes showed hypokalaemia (potassium 2.6 meq l−1).", + "Random blood sugar on admission was 274 mg dl−1.", + "He tested negative for HIV, HCV, and HBV.", + "Ultrasonography showed fatty hepatomegaly with focal lesions in the liver.", + "Computed tomography showed several hypodense lesions involving segment 5 of the liver.", + "Computed tomography showed mild hepatomegaly.", + "Computed tomography of the lungs showed cavitation in the upper lobes of both lungs.", + "Upper gastrointestinal endoscopy was normal.", + "Stool was sent for microscopy and bacteriological culture.", + "Macroscopically, the stool was watery, yellowish coloured, with no mucus or blood.", + "Wet preparation revealed numerous motile larvae in the rhabditiform stage.", + "The larvae measured 100–400 µm in length×15–20 µm in width.", + "The larvae had a short buccal cavity.", + "There were a few oval shaped eggs with larvae, suggestive of S. stercoralis.", + "Stool microscopy following the formal ether concentration technique did not show any additional findings.", + "Stool microscopy was repeated with freshly collected stool samples on three separate occasions.", + "The repeated stool microscopy also demonstrated motile rhabditiform larvae of S. stercoralis.", + "Agar culture method was performed to visualize the positive trail sign.", + "The agar culture showed a ‘positive trail sign’.", + "The agar culture method was to be repeated after therapy.", + "The bacteriological culture of stool yielded Aeromonas sobria.", + "Aeromonas sobria was sensitive to ciprofloxacin, chloramphenicol, tetracycline, and cotrimoxazole.", + "Stool occult blood was negative.", + "Stool toxin (VIDAS difficile toxin A and B) was negative.", + "The diagnosis was hyperinfection syndrome with disseminated strongyloidiasis.", + "The diagnosis included alcoholic liver disease.", + "The diagnosis included type 2 diabetes mellitus.", + "The diagnosis included hypertension.", + "The diagnosis included dyslipidaemia.", + "The diagnosis included pulmonary tuberculosis.", + "Therapy included blood sugar and electrolyte correction.", + "The patient was empirically started on ciprofloxacin intravenously.", + "Following the stool microscopy report, a stat oral dose of a combination of albendazole 400 mg and ivermectin 6 mg was given.", + "The patient was continued on ciprofloxacin IV for 4 days.", + "He showed symptomatic improvement by the second day of treatment.", + "His stool became semisolid in consistency.", + "The number of motile larvae in fresh stool showed an appreciable reduction.", + "He was discharged after 4 days on mixtard insulin and oral ciprofloxacin 500 mg twice daily for 3 days.", + "The patient was readmitted on the third day of discharge with complaints of fever and recurrence of diarrhoea.", + "His blood sugar value at the time of readmission was 210 mg dl−1.", + "His total leucocyte count was 12 000 cumm−1.", + "Differential count showed polymorphs 60 %.", + "Blood was sent for culture.", + "Empirical therapy was initiated with injected piperacillin/tazobactam and mixtard insulin.", + "On day 2 of readmission, he expired.", + "Aeromonas sobria was isolated from his blood culture 3 days after readmission.", + "Aeromonas sobria was sensitive to cephalosporins, carbapenems, piperacillin/tazobactam, and aminoglycosides.", + "Aeromonas sobria was resistant to ciprofloxacin." + ], + "summary": "We report a case of chronic diarrhoea and decreased appetite in a 53-year-old man. He was a chronic alcoholic with diabetes, hypertension and dyslipidaemia and had earlier been treated for pulmonary tuberculosis. He was treated symptomatically for loose stools at a primary health care facility without relief. Following referral to our tertiary care centre, microscopic examination of the stool showed numerous larvae and a few eggs of Strongyloides stercoralis. Additionally, Aeromonas sobria was isolated from stool culture. The patient was discharged following improvement with a combination therapy of ivermectin, albendazole and ciprofloxacin. However, within 3 days, he was readmitted and succumbed to Escherichia coli sepsis.", + "summary_subclaims": [ + "The patient was a 53-year-old man.", + "The patient had chronic diarrhoea.", + "The patient had decreased appetite.", + "The patient was a chronic alcoholic.", + "The patient had diabetes.", + "The patient had hypertension.", + "The patient had dyslipidaemia.", + "The patient had been treated for pulmonary tuberculosis.", + "The patient was treated symptomatically for loose stools at a primary health care facility.", + "The treatment at the primary health care facility did not provide relief.", + "The patient was referred to a tertiary care centre.", + "Microscopic examination of the stool showed numerous larvae of Strongyloides stercoralis.", + "Microscopic examination of the stool showed a few eggs of Strongyloides stercoralis.", + "Aeromonas sobria was isolated from stool culture.", + "The patient was discharged following improvement.", + "The patient received a combination therapy of ivermectin, albendazole and ciprofloxacin.", + "The patient was readmitted within 3 days.", + "The patient succumbed to Escherichia coli sepsis." + ] + }, + { + "id": "multiclinsum_test_1805_en.txt", + "fulltext": "A 52-year-old overweight white woman with hypertension and a 3-years history of chronic kidney disease stage II K-DOQI was referred to our Nephrology department for worsening renal function and resistant hypertension.\nLaboratory analysis showed a mild asymptomatic anemia, serum creatinine 1.9 mg/dl, with non-selective nephrotic proteinuria, Bence-Jones proteinuria, and extremely elevated serum kappa free light chains (FLC). Total calcemia was persistently normal and no bone lesions or full-blown nephrotic syndrome were present. Although coagulation profile was persistently not evaluable, probably due to the interfering monoclonal protein, bleeding time was in the normal range .\nA bone marrow biopsy revealed a complete metaplasia of clonal plasma cells with > 90% of clonal plasma cells and cytogenetic analysis (FISH) confirmed the diagnosis of micromolecular kappa MM with high-risk chromosomal abnormalities, R-ISS 3. All clonal plasma cells carried translocation t(14;16) on IGH/MAF gene. Complete immunoparesis was also noticed, while CRAB criteria were not reported.\nPatient showed increased NT-proBNP and high-sensitivity troponin (hs-cTnT) suggesting cardiac involvement. ECG showed tachycardia, first degree AV block and right axial deviation with right conduction delay. Unexpectedly, Congo-red stain on abdominal fat was negative for amyloid deposition. Transthoracic echocardiogram (TTE) revealed a 4.4 × 2.8 cm right atrial mass projecting through the tricuspid valve orifice, and a second 1.5 cm mass located at the right ventricle (RV) apex. Function and motility of both ventricles were preserved, and no sign of left ventricular (LV) hypertrophy was present (interventricular septum 10 mm, LV posterior wall 8 mm). No significant valvular regurgitations were identified.\nA computed tomography (CT) pulmonary angiogram showed RV thrombi, a large thrombus involving the pulmonary trunk and its two main right and left branches, as well as the segmental basal branches of the left lung. A partial thrombosis was described in the inferior vena cava from its intrahepatic tract to the origin of the renal veins (extended for about 7,5 cm) . Complete thrombosis of the left renal vein was also detected. Remarkably, the patient reported only mild asthenia, normal blood pressure, no dyspnea, and 99% oxygen saturation in room air. Since she was hemodynamically stable, unfractionated heparin was promptly started but, according to the thrombosis extension and the high risk of embolization, the patient was referred to cardiac surgery.\nThrough a midline-sternotomy approach, a bilateral pulmonary thrombus was removed en-bloc with attached casts of the lobar branches across an incision in the pulmonary artery.\nBoth masses from the right chambers were removed through the right atrium , while the thrombus into the inferior vena cava was too firmly attached to the vessel wall to be extracted. Cardiopulmonary bypass was terminated without inotropic supports. After surgery, patient restarted anticoagulation therapy with unfractionated heparin, subsequently substituted by warfarin.\nMeantime, a kidney biopsy was performed and light microscopy showed a moderately increased glomerular mesangial matrix without endo or extracapillary proliferation. No morphological lesions such as mesangial nodules or nodular glomerulosclerosis were recognized and none of the glomeruli were sclerotic. There was a grade 1 interstitial fibrosis (IF < 25%) with small areas of lymphocytic infiltrate. Also, rare inflammatory hyaline casts were found in the tubules in the absence of concurrent cast-nephropathy. Vascular compartment was practically normal according to patient’s age . Congo red staining was once again negative. Immunofluorescence (IF) on fresh frozen unfixed tissue was not contributory, with only weak (± or 1 +) staining for C3 and kappa FLC . Differently, IF on fixed tissue demonstrated an intense (3 +) linear staining for kappa FLC along the glomerular and tubular basement membranes, while IgG, lambda, and C3 staining were negative . Electron microscopy showed segmentary “ground pepper-like” deposits in the subendothelial space and the glomerular basement membranes (GBM). Similar deposits were observed along the tubular basement membrane (TBM). Extensive podocyte foot process effacement was seen with no sub-epithelial or mesangial electron-dense deposits . The final diagnosis was “kappa light chain deposition disease (LCDD)”.\nThe patient fully recovered from surgery. A new TTE showed preserved function of both ventricles (EF 58%, TAPSE 20 mm, RV-RA gradient 25 mmHg) or major valvular disease. No new intracardiac masses were detected (video, Additional file 1).\nA 3-months follow-up CT showed the persistence of only a partially calcified thrombus in the right pulmonary artery’s distal branches, warfarin was continued.\nAfter 4 cycles of VTD protocol (Bortezomib, Thalidomide, Dexamethasone), the patient presented a very-good partial hematologic remission. Afterwards, she received autologous hematopoietic stem cell transplantation, with a stable complete hematologic remission and a progressive improvement of proteinuria and renal function .", + "fulltext_subclaims": [ + "The patient is a 52-year-old overweight white woman.", + "She has a 3-year history of chronic kidney disease stage II K-DOQI.", + "She was referred to the Nephrology department for worsening renal function and resistant hypertension.", + "Laboratory analysis showed a mild asymptomatic anemia.", + "Serum creatinine was 1.9 mg/dl.", + "There was non-selective nephrotic proteinuria.", + "Bence-Jones proteinuria was present.", + "Extremely elevated serum kappa free light chains were observed.", + "Total calcemia was persistently normal.", + "No bone lesions were present.", + "No full-blown nephrotic syndrome was present.", + "Coagulation profile was persistently not evaluable.", + "Bleeding time was in the normal range.", + "A bone marrow biopsy revealed a complete metaplasia of clonal plasma cells with > 90% of clonal plasma cells.", + "Cytogenetic analysis confirmed the diagnosis of micromolecular kappa MM with high-risk chromosomal abnormalities.", + "The patient had R-ISS 3.", + "All clonal plasma cells carried translocation t(14;16) on IGH/MAF gene.", + "Complete immunoparesis was noticed.", + "CRAB criteria were not reported.", + "The patient showed increased NT-proBNP.", + "High-sensitivity troponin (hs-cTnT) was increased.", + "ECG showed tachycardia.", + "ECG showed first degree AV block.", + "ECG showed right axial deviation with right conduction delay.", + "Congo-red stain on abdominal fat was negative for amyloid deposition.", + "Transthoracic echocardiogram revealed a 4.4 × 2.8 cm right atrial mass projecting through the tricuspid valve orifice.", + "A second 1.5 cm mass was located at the right ventricle apex.", + "Function and motility of both ventricles were preserved.", + "No sign of left ventricular hypertrophy was present.", + "Computed tomography pulmonary angiogram showed RV thrombi.", + "A large thrombus involved the pulmonary trunk and its two main right and left branches.", + "A partial thrombosis was described in the inferior vena cava.", + "The patient reported only mild asthenia.", + "She had normal blood pressure.", + "She had 99% oxygen saturation in room air.", + "Unfractionated heparin was promptly started.", + "The patient was referred to cardiac surgery.", + "A bilateral pulmonary thrombus was removed en-bloc with attached casts of the lobar branches.", + "Both masses from the right chambers were removed through the right atrium.", + "The thrombus into the inferior vena cava was too firmly attached to be extracted.", + "After surgery, anticoagulation therapy with unfractionated heparin was restarted.", + "Warfarin was substituted for unfractionated heparin.", + "A kidney biopsy was performed.", + "Light microscopy showed a moderately increased glomerular mesangial matrix.", + "No morphological lesions such as mesangial nodules or nodular glomerulosclerosis were recognized.", + "There was a grade 1 interstitial fibrosis with small areas of lymphocytic infiltrate.", + "Rare inflammatory hyaline casts were found in the tubules.", + "Vascular compartment was practically normal according to patient’s age.", + "Congo red staining was once again negative.", + "Immunofluorescence on fresh frozen unfixed tissue showed only weak staining for C3 and kappa FLC.", + "Immunofluorescence on fixed tissue demonstrated an intense linear staining for kappa FLC along the glomerular and tubular basement membranes.", + "Electron microscopy showed segmentary ground pepper-like deposits in the subendothelial space.", + "Extensive podocyte foot process effacement was seen.", + "The final diagnosis was kappa light chain deposition disease (LCDD).", + "The patient fully recovered from surgery.", + "A new TTE showed preserved function of both ventricles.", + "No new intracardiac masses were detected.", + "A 3-months follow-up CT showed the persistence of only a partially calcified thrombus in the right pulmonary artery’s distal branches.", + "Warfarin was continued.", + "After 4 cycles of VTD protocol, the patient presented a very-good partial hematologic remission.", + "She received autologous hematopoietic stem cell transplantation.", + "She had a stable complete hematologic remission.", + "There was a progressive improvement of proteinuria.", + "There was a progressive improvement of renal function." + ], + "summary": "We present an unusual multidisciplinary case of a woman with a newly diagnosed MM associated with severe proteinuria and high natriuretic peptide. A renal and fat pad biopsy with Congo red staining were performed but amyloid deposition was not discovered. While immunofluorescence on fresh frozen unfixed tissue was not contributory, the immunofluorescence on fixed tissue and electron microscopy revealed the correct diagnosis. During subsequent investigations, two intracardiac right-sided masses and massive pulmonary embolism were also detected.", + "summary_subclaims": [ + "The patient had a newly diagnosed MM.", + "The patient had severe proteinuria.", + "The patient had high natriuretic peptide.", + "A renal and fat pad biopsy with Congo red staining were performed.", + "Amyloid deposition was not discovered.", + "Immunofluorescence on fresh frozen unfixed tissue was not contributory.", + "Immunofluorescence on fixed tissue revealed the correct diagnosis.", + "Electron microscopy revealed the correct diagnosis.", + "Two intracardiac right-sided masses were detected.", + "Massive pulmonary embolism was detected." + ] + }, + { + "id": "multiclinsum_test_1964_en.txt", + "fulltext": "A 75-year-old Japanese male was transferred from another hospital after presenting with hemorrhagic shock due to hematochezia. He had been transported by ambulance to the previous hospital after complaining of discomfort and bloody stool on the previous day. He had undergone distal pancreatectomy and right lower lobectomy for pancreatic cancer and lung cancer, respectively, 5 years prior and total pancreatectomy due to residual pancreatic cancer eight months prior. The reconstruction procedure consisted of hepaticojejunostomy, Braun’s anastomosis, and gastrojejunostomy. In addition, a stent had been inserted for stenosis of the hepaticojejunostomy 1 month prior. The patient’s medical history also included atrial fibrillation, and he was taking insulin and apixaban. On arrival, he appeared to be pale and his extremities were cold. His vital signs were as follows: respiratory rate, 20 breaths/min; pulse rate, 105 beats/min (bpm); blood pressure, 77/54 mmHg; temperature, 34.9 °C. Arterial blood gas analysis detected severe lactic acidosis (lactate concentration: 9.9 mmol/L) and anemia (hemoglobin level: 3.1 g/dL). The laboratory data showed a white blood cell count of 5850/μL, C-reactive protein level of 0.08 mg/dL, procalcitonin level of 0.097 ng/mL, and serum glucose level of 389 mg/dL. Contrast-enhanced computed tomography of the abdomen did not detect any active bleeding. His melena had already ceased. Fluid resuscitation and massive transfusions resolved his hemorrhagic shock. Crystalloids were administered 800 mL over an hour. Blood products were initiated 30 min after the patient’s arrival. The patient required 16 units of red blood cell concentrate, 14 units of fresh frozen plasma and 20 units of platelets within 12 h of his arrival for hemostatic resuscitation. A classification of hemorrhage of the patient was considered as class IV based on the American College of Surgeons. Urgent upper gastrointestinal endoscopy was a poor study because of food residue and failed to identify the source of the patient’s bleeding. Thus, he was admitted to the emergency intensive care unit for careful observation. The patient’s acute physiology and chronic health evaluation (APACHE II) score on the day of admission was 24, and the Charlson comorbidity index was three.\nSince fresh bleeding was detected in the terminal ileum during capsule endoscopy the next day, colonoscopy was performed without bowel cleaning. But the exam produced poor findings due to blood clot. Therefore, transanal double balloon enteroscopy was scheduled for further investigation 4 days after the patient’s admission. The patient took 5 h to ingest 2 L of PEG plus an additional liter of PEG for bowel preparation. This was the first time he had consumed PEG. 1 h after consuming the 3 L of PEG, he complained of a feverish chill and his heart rate and temperature increased to over 130 bpm and 39 °C, respectively. The transanal double balloon enteroscopy exam was performed uneventfully and did not reveal the source of the patient’s bleeding.\nAfter the examination, he appeared to be agitated and distressed and exhibited hypotension, high fever, and an elevated lactate level, which indicated septic shock. He did not have any other complaints. His abdomen was soft, flat, and non-tender. Empirical antibiotic therapy with meropenem was administered, and two sets of blood cultures were obtained at the same time. Fluid resuscitation and a noradrenaline infusion were initiated due to septic shock, followed by intubation and mechanical ventilation. Table shows the patient’s laboratory data at the time that he suffered septic shock. Repeated lab tests revealed a significantly elevated procalcitonin level. Liver function tests produced normal results during the course, so we excluded biliary stent infection. Figure shows the patient’s clinical course during the first 15 h after he ingested PEG, the hypotensive phase of his condition, and the resuscitation period. Ongoing intensive care led to a gradual improvement in the patient’s condition and he was successfully extubated on day 4 (the day when the PEG preparation was administered was defined as day 0, at which APACHE II score was 34). An examination of his blood cultures detected C. braakii and we replaced the meropenem with ceftazidime based on the results of sensitivity tests. Later, the identity of the pathogen was confirmed by biochemical analysis and partial sequencing of 16S rRNA. Urinalysis produced normal results. Cultures of the patient’s urine and sputum at the onset of septic shock were negative. The tip cultures of central venous catheter which had been placed in a femoral vein on admission were found to be negative. Stool culture was obtained 1 week after presenting septic shock, which was also negative. Antibiotics were administered for a total of 10 days. The patient was discharged from the emergency intensive care unit on day 8. Figure shows the patient’s clinical course over the 8 days after he first suffered septic shock.\nMelena occurred intermittently. Upper gastrointestinal endoscopy subsequently identified marginal ulceration of the gastrojejunal anastomosis, which was successfully treated with coagulation hemostasis. The patient was discharged on day 33.", + "fulltext_subclaims": [ + "The patient was a 75-year-old Japanese male.", + "He was transferred after presenting with hemorrhagic shock due to hematochezia.", + "He had undergone distal pancreatectomy and right lower lobectomy for pancreatic cancer and lung cancer, respectively, 5 years prior.", + "He had total pancreatectomy due to residual pancreatic cancer eight months prior.", + "The reconstruction procedure consisted of hepaticojejunostomy, Braun’s anastomosis, and gastrojejunostomy.", + "A stent had been inserted for stenosis of the hepaticojejunostomy 1 month prior.", + "He was taking insulin and apixaban.", + "On arrival, his blood pressure was 77/54 mmHg.", + "Arterial blood gas analysis detected severe lactic acidosis (lactate concentration: 9.9 mmol/L).", + "The hemoglobin level was 3.1 g/dL.", + "Contrast-enhanced computed tomography of the abdomen did not detect any active bleeding.", + "Melena had already ceased.", + "Fluid resuscitation and massive transfusions resolved his hemorrhagic shock.", + "The patient required 16 units of red blood cell concentrate within 12 h of his arrival.", + "The patient required 14 units of fresh frozen plasma within 12 h of his arrival.", + "The patient required 20 units of platelets within 12 h of his arrival.", + "The patient’s hemorrhage was classified as class IV based on the American College of Surgeons.", + "Urgent upper gastrointestinal endoscopy was a poor study because of food residue.", + "The APACHE II score on the day of admission was 24.", + "The Charlson comorbidity index was three.", + "Fresh bleeding was detected in the terminal ileum during capsule endoscopy the next day.", + "Colonoscopy was performed without bowel cleaning.", + "The exam produced poor findings due to blood clot.", + "Transanal double balloon enteroscopy was scheduled for further investigation 4 days after the patient’s admission.", + "The patient took 5 h to ingest 2 L of PEG plus an additional liter of PEG for bowel preparation.", + "This was the first time he had consumed PEG.", + "1 h after consuming the 3 L of PEG, he complained of a feverish chill.", + "His heart rate increased to over 130 bpm.", + "His temperature increased to 39 °C.", + "The transanal double balloon enteroscopy exam was performed uneventfully.", + "The exam did not reveal the source of the patient’s bleeding.", + "After the examination, he exhibited hypotension, high fever, and an elevated lactate level, which indicated septic shock.", + "Empirical antibiotic therapy with meropenem was administered.", + "Two sets of blood cultures were obtained.", + "Fluid resuscitation and a noradrenaline infusion were initiated due to septic shock.", + "Intubation and mechanical ventilation were performed.", + "Repetitive lab tests revealed a significantly elevated procalcitonin level.", + "Liver function tests produced normal results.", + "The tip cultures of central venous catheter were found to be negative.", + "Stool culture was obtained 1 week after presenting septic shock, which was also negative.", + "Antibiotics were administered for a total of 10 days.", + "The patient was discharged from the emergency intensive care unit on day 8.", + "An examination of his blood cultures detected C. braakii.", + "The meropenem was replaced with ceftazidime based on the results of sensitivity tests.", + "The identity of the pathogen was confirmed by biochemical analysis and partial sequencing of 16S rRNA.", + "Upper gastrointestinal endoscopy subsequently identified marginal ulceration of the gastrojejunal anastomosis.", + "The marginal ulceration was successfully treated with coagulation hemostasis.", + "The patient was discharged on day 33." + ], + "summary": "A 75-year-old Japanese male who had previously developed diabetes after total pancreatectomy received PEG in preparation for colonoscopy. He had been admitted to the emergency intensive care unit 4 days earlier due to hematochezia presenting with shock. He ingested PEG to prepare for a colonoscopy examination, which was performed to identify the source of his bleeding over a 5-h period, but suddenly exhibited septic shock and markedly elevated procalcitonin levels. A blood culture subsequently revealed Citrobacter braakii. Immediate resuscitation and intensive care with appropriate antibiotics improved his condition.", + "summary_subclaims": [ + "The patient is a 75-year-old Japanese male.", + "The patient had previously developed diabetes after total pancreatectomy.", + "The patient received PEG in preparation for colonoscopy.", + "The patient had been admitted to the emergency intensive care unit 4 days earlier due to hematochezia presenting with shock.", + "The patient ingested PEG to prepare for a colonoscopy examination.", + "The colonoscopy was performed to identify the source of his bleeding over a 5-h period.", + "The patient suddenly exhibited septic shock.", + "The patient had markedly elevated procalcitonin levels.", + "A blood culture revealed Citrobacter braakii.", + "Immediate resuscitation and intensive care with appropriate antibiotics improved his condition." + ] + }, + { + "id": "multiclinsum_test_742_en.txt", + "fulltext": "A 24-year-old Japanese woman with no notable past medical history presented with complaints of fever and nausea while she was traveling in Australia; within the previous 2 months, she had also traveled to India and Africa. She visited a local hospital in Australia, and the laboratory tests showed significantly elevated levels of transaminase, so she was checked for viral hepatitis. After excluding hepatitis A, B, and C, as well as other causes of hepatitis, it was revealed that the patient was positive for HEV-IgM. Since she was a visitor to Australia, she was sent back to Japan and was transferred to our hospital. During her stay in India and Africa, she ate most of her meals at local restaurants, and she sometimes drank tap water.\nHer initial vital signs revealed a blood pressure of 103/64 mmHg, heart rate of 84 beats/min, and body temperature of 36.4 °C. Physical examination revealed jaundice with no tenderness over the right upper quadrant. The chest, extremities, and other systemic examinations were unremarkable. Laboratory investigations revealed an aspartate aminotransferase (AST) level of 1382 U/L, alanine aminotransferase (ALT) level of 2842 U/L, total bilirubin level of 4.8 mg/dL, and direct bilirubin level of 3.9 mg/dL. The test results were all negative for anti-nuclear antibody, anti-mitochondrial antibody, cytomegalovirus IgG and IgM, Epstein-Barr virus, and hepatitis A, B, and C antibodies; but the test for HEV-IgM was positive . Her initial ultrasonography of the abdomen revealed splenomegaly (108 × 39 mm) and a small amount of ascites, but no signs of hepatomegaly or an enlarged gallbladder. According to the data above, HEV infection was diagnosed.\nShe was treated with intravenous fluids with normal saline. On day 4, the patient complained of right upper quadrant pain. Ultrasonography of the abdomen showed 3 mm of a gallbladder wall; moreover, a physical examination detected tenderness over the right upper quadrant and positive Murphy’s sign. Since the levels of transaminase and total bilirubin were gradually declining at that time, the enlarged gallbladder was left untreated, but closely followed up. However, the level of AST was elevated again at 980 U/L on day 7. In addition to the ultrasonographic findings, perivesical fluid accumulation and an edematous gallbladder wall (4 mm) had appeared . There were no stones in the gallbladder. In addition, there were no other causes of acalculous cholecystitis. Pneumonia, acute pancreatitis, hepatic or subphrenic abscess, and right pyelonephritis were considered for the possible causes but were excluded from the diagnosis due to the fact that no evidence was shown on ultrasonographic findings, urinalysis, and chest X-ray. No antibiotics were administered for the cholecystitis. From day 9, the levels of transaminase and bilirubin began to decline even without the use of antibiotics. Blood culture was negative, and the procalcitonin level was within the normal range. Based on these findings, we assessed the cholecystitis was not caused by bacterial infection and decided not to administer any antibiotics. The edematous wall showed significant improvement on day 11 and had returned to normal by day 14. Since the patient did not complain of abdominal pain and the findings were gradually being recovered, it was not necessary to intervene surgically. The patient was discharged on day 16 because all of the symptoms had disappeared.\nThe serum of the patient was tested to identify the genotype of the HEV at the Osaka Prefectural Institute of Public Health, and it was identified to be HEV genotype 1, OSN2015-5 . It was confirmed by using SuperScript III-one step RT-PCR system with Platinum Taq (Invitrogen).\nFrom this case, two important clinical discoveries were made: (1) HEV can cause acalculous cholecystitis as an extrahepatic manifestation, and (2) it can recover without any antibiotics.\nFirst, HEV can cause acalculous cholecystitis as an extrahepatic symptom. It has been reported that HEV can cause pancreatitis, arthropathy, aplastic anemia, and Guillain-Barre syndrome as extrahepatic symptoms [, ]; however, acalculous cholecystitis has not been previously reported as a symptom of HEV. We performed a search of the MEDLINE database for the terms ‘cholecystitis’ and ‘viral hepatitis E’. Three hits were found, but the contexts were unrelated to cholecystitis due to HEV. Hepatitis A virus infection is known to cause acalculous cholecystitis as a rare complication . Although further investigations of a larger number of cases are needed to clarify the matter, it is presumed that hepatitis A virus invades the endothelial cells of the gallbladder and bile duct and induces cell-mediated immunity [, ]. However, this is the first case report of acalculous cholecystitis as an extrahepatic manifestation of HEV.\nSecond, the acalculous cholecystitis due to HEV infection could recover without any antibiotics. On the seventh day after admission, the level of serum AST was increased, and ultrasonography of the abdomen detected a thickened gallbladder wall without calculi and perivesical fluid accumulation; these met the criteria for acalculous cholecystitis . In general, the treatment options for acalculous cholecystitis are antibiotics, drainage, and/or operation. However, none of them were necessary in this case, and the patient recovered completely. According to the clinical course, the cholecystitis was secondary to HEV infection and recovered as the HEV infection resolved.\nHumans can be infected by four different genotypes of HEV: genotypes 1, 2, 3, and 4. HEV genotypes 1 and 2 are common and restricted to human . Individuals may become infected with HEV genotypes 1 and 2 from drinking contaminated water, so it was suspected that this patient became infected with HEV from drinking tap water in India. Genotype 1 is prevalent in the Indian subcontinent, Asia, the Middle East, and Africa . The latent period of HEV infection is approximately 6 to 8 weeks . Based on the travel history of the patient, it is possible that she became infected with HEV while she was in India. HEV infection does not affect only developing countries. HEV genotypes 3 and 4 are found in some industrialized countries. In addition, zoonotic transmission to humans is possible with HEV genotypes 3 and 4 . Occasional foodborne outbreaks from the consumption of undercooked meat contaminated with HEV have occurred in Europe, North America, Japan, and New Zealand . Among the different genotypes, genotype 1 HEV infection can cause the most serious disease . As such, it is important to determine the genotype of the HEV infecting a patient to know the prognosis and to identify the source of the infection.", + "fulltext_subclaims": [ + "The patient was a 24-year-old Japanese woman.", + "She had no notable past medical history.", + "She presented with complaints of fever and nausea while traveling in Australia.", + "Within the previous 2 months, she had also traveled to India and Africa.", + "She visited a local hospital in Australia.", + "The laboratory tests showed significantly elevated levels of transaminase.", + "She was checked for viral hepatitis.", + "Hepatitis A, B, and C were excluded.", + "Other causes of hepatitis were excluded.", + "The patient was positive for HEV-IgM.", + "She was sent back to Japan and transferred to the hospital.", + "During her stay in India and Africa, she ate most of her meals at local restaurants.", + "She sometimes drank tap water.", + "Her initial vital signs revealed a blood pressure of 103/64 mmHg.", + "Her initial vital signs revealed a heart rate of 84 beats/min.", + "Her initial vital signs revealed a body temperature of 36.4 °C.", + "Physical examination revealed jaundice.", + "There was no tenderness over the right upper quadrant.", + "The chest, extremities, and other systemic examinations were unremarkable.", + "Laboratory investigations revealed an AST level of 1382 U/L.", + "Laboratory investigations revealed an ALT level of 2842 U/L.", + "Laboratory investigations revealed a total bilirubin level of 4.8 mg/dL.", + "Laboratory investigations revealed a direct bilirubin level of 3.9 mg/dL.", + "The test results were all negative for anti-nuclear antibody.", + "The test results were all negative for anti-mitochondrial antibody.", + "The test results were all negative for cytomegalovirus IgG and IgM.", + "The test results were all negative for Epstein-Barr virus.", + "The test results were all negative for hepatitis A, B, and C antibodies.", + "The test for HEV-IgM was positive.", + "Initial ultrasonography of the abdomen revealed splenomegaly.", + "Initial ultrasonography of the abdomen revealed a small amount of ascites.", + "No signs of hepatomegaly were found.", + "No signs of an enlarged gallbladder were found.", + "HEV infection was diagnosed.", + "She was treated with intravenous fluids with normal saline.", + "On day 4, the patient complained of right upper quadrant pain.", + "Ultrasonography of the abdomen showed a 3 mm gallbladder wall.", + "A physical examination detected tenderness over the right upper quadrant.", + "Murphy’s sign was positive.", + "The levels of transaminase and total bilirubin were gradually declining.", + "The enlarged gallbladder was left untreated.", + "The enlarged gallbladder was closely followed up.", + "The level of AST was elevated again at 980 U/L on day 7.", + "Ultrasonographic findings showed perivesical fluid accumulation.", + "Ultrasonographic findings showed an edematous gallbladder wall (4 mm).", + "There were no stones in the gallbladder.", + "There were no other causes of acalculous cholecystitis.", + "Pneumonia, acute pancreatitis, hepatic or subphrenic abscess, and right pyelonephritis were considered.", + "These were excluded due to no evidence on ultrasonographic findings, urinalysis, and chest X-ray.", + "No antibiotics were administered for the cholecystitis.", + "The levels of transaminase and bilirubin began to decline without antibiotics.", + "Blood culture was negative.", + "The procalcitonin level was within the normal range.", + "The cholecystitis was assessed as not caused by bacterial infection.", + "No antibiotics were administered.", + "The edematous wall showed significant improvement on day 11.", + "The edematous wall had returned to normal by day 14.", + "The patient did not complain of abdominal pain.", + "The findings were gradually being recovered.", + "It was not necessary to intervene surgically.", + "The patient was discharged on day 16.", + "All of the symptoms had disappeared.", + "The serum of the patient was tested to identify the genotype of the HEV.", + "The genotype was identified as HEV genotype 1, OSN2015-5.", + "It was confirmed by using SuperScript III-one step RT-PCR system with Platinum Taq.", + "HEV can cause acalculous cholecystitis as an extrahepatic manifestation.", + "The acalculous cholecystitis due to HEV infection could recover without any antibiotics.", + "HEV can cause acalculous cholecystitis as an extrahepatic symptom.", + "Acalculous cholecystitis has not been previously reported as a symptom of HEV.", + "Three hits were found in the MEDLINE database for the terms ‘cholecystitis’ and ‘viral hepatitis E’.", + "The contexts were unrelated to cholecystitis due to HEV.", + "Hepatitis A virus infection is known to cause acalculous cholecystitis as a rare complication.", + "It is presumed that hepatitis A virus invades the endothelial cells of the gallbladder and bile duct.", + "This is the first case report of acalculous cholecystitis as an extrahepatic manifestation of HEV.", + "The acalculous cholecystitis due to HEV infection could recover without any antibiotics.", + "On the seventh day after admission, the level of serum AST was increased.", + "Ultrasonography of the abdomen detected a thickened gallbladder wall without calculi.", + "Ultrasonography of the abdomen detected perivesical fluid accumulation.", + "These met the criteria for acalculous cholecystitis.", + "The treatment options for acalculous cholecystitis are antibiotics, drainage, and/or operation.", + "None of them were necessary in this case.", + "The patient recovered completely.", + "The cholecystitis was secondary to HEV infection.", + "The cholecystitis recovered as the HEV infection resolved.", + "Humans can be infected by four different genotypes of HEV: genotypes 1, 2, 3, and 4.", + "HEV genotypes 1 and 2 are common and restricted to humans.", + "Individuals may become infected with HEV genotypes 1 and 2 from drinking contaminated water.", + "It was suspected that this patient became infected with HEV from drinking tap water in India.", + "Genotype 1 is prevalent in the Indian subcontinent, Asia, the Middle East, and Africa.", + "The latent period of HEV infection is approximately 6 to 8 weeks.", + "Based on the travel history of the patient, it is possible that she became infected with HEV while she was in India.", + "HEV infection does not affect only developing countries.", + "HEV genotypes 3 and 4 are found in some industrialized countries.", + "Zoonotic transmission to humans is possible with HEV genotypes 3 and 4.", + "Occasional foodborne outbreaks from the consumption of undercooked meat contaminated with HEV have occurred.", + "These outbreaks have occurred in Europe, North America, Japan, and New Zealand.", + "Among the different genotypes, genotype 1 HEV infection can cause the most serious disease.", + "It is important to determine the genotype of the HEV infecting a patient to know the prognosis.", + "It is important to determine the genotype of the HEV infecting a patient to identify the source of the infection." + ], + "summary": "A 24-year-old Japanese woman with no notable past medical history presented with complaints of fever and nausea while she was traveling in Australia; within the previous 2 months, she had also traveled to India and Africa. She visited a local hospital in Australia, and the laboratory tests showed significantly elevated levels of transaminase, so she was checked for viral hepatitis. After excluding hepatitis A, B, and C, as well as other causes of hepatitis, it was revealed that the patient was positive for HEV-IgM. Since she was a visitor to Australia, she was sent back to Japan and was transferred to our hospital. On day 4, the patient complained of right upper quadrant pain. Ultrasonography of the abdomen showed a thickened gallbladder wall without calculi. Acalculous cholecystitis was diagnosed from her course. No antibiotics were administered against it because there was no evidence of bacterial infection. The edematous wall showed significant improvement on day 11 and had returned to normal by day 14. The patient was discharged on day 16 because all of the symptoms had disappeared.", + "summary_subclaims": [ + "The patient is a 24-year-old Japanese woman.", + "She had no notable past medical history.", + "She presented with complaints of fever and nausea.", + "She was traveling in Australia when she presented.", + "Within the previous 2 months, she had also traveled to India and Africa.", + "She visited a local hospital in Australia.", + "The laboratory tests showed significantly elevated levels of transaminase.", + "She was checked for viral hepatitis.", + "Hepatitis A, B, and C were excluded.", + "Other causes of hepatitis were excluded.", + "The patient was positive for HEV-IgM.", + "She was sent back to Japan.", + "She was transferred to our hospital.", + "On day 4, the patient complained of right upper quadrant pain.", + "Ultrasonography of the abdomen showed a thickened gallbladder wall without calculi.", + "Acalculous cholecystitis was diagnosed from her course.", + "No antibiotics were administered against it.", + "There was no evidence of bacterial infection.", + "The edematous wall showed significant improvement on day 11.", + "The gallbladder wall had returned to normal by day 14.", + "The patient was discharged on day 16.", + "All of the symptoms had disappeared." + ] + }, + { + "id": "multiclinsum_test_679_en.txt", + "fulltext": "A 48-year-old man had persistent severe right groin pain after activity for 9 months. He had played tennis and skied for over 20 years. Although he had full range of movement at the hip, he complained of pain on internal rotation. He experienced pain when undergoing both the flexion-adduction-internal rotation test and flexion-abduction-external rotation test. A radiograph of the hip showed acetabular dysplasia with a center-edge angle of 15 degrees . A cystic lesion was detected on magnetic resonance imaging (MRI) with T1- and T2-weighted images showing low and high signal intensity, respectively. Short inversion time inversion recovery images revealed an adjacent teardrop-shaped lesion (-). He underwent arthroscopic surgery under general anesthesia, during which he was placed in the supine position, and appropriate traction was applied on a traction table. A lateral portal was created over the tip of the greater trochanter and an anterolateral portal was placed between the lateral portal and the femoral artery and slightly distal to the transverse line. An anterior portal was established at the inguinal groove slightly lateral to the femoral artery. During arthroscopic evaluation of the central compartment, a cystic mass was identified between the transverse acetabular ligament (TAL) and ligamentum teres and in continuity with the TAL . When the cyst was punctured, a blood-streaked yellowish viscous liquid was expelled . The remaining cyst wall was resected in its entirety . Histological examination revealed a glassy fibrous tissue wall without lining cells, confirming a diagnosis of ganglion cyst .\nAfter surgery, weight-bearing was permitted as tolerated and the patient returned to recreational sports 6 months later. No recurrence was detected on MRI at the 6-year follow-up postoperatively ( and ), the patient had no complaints at that time.", + "fulltext_subclaims": [ + "The patient is a 48-year-old man.", + "He had persistent severe right groin pain after activity for 9 months.", + "He had played tennis and skied for over 20 years.", + "He had full range of movement at the hip.", + "He complained of pain on internal rotation.", + "He experienced pain when undergoing the flexion-adduction-internal rotation test.", + "He experienced pain when undergoing the flexion-abduction-external rotation test.", + "A radiograph of the hip showed acetabular dysplasia with a center-edge angle of 15 degrees.", + "A cystic lesion was detected on magnetic resonance imaging.", + "T1-weighted images showed low signal intensity.", + "T2-weighted images showed high signal intensity.", + "Short inversion time inversion recovery images revealed an adjacent teardrop-shaped lesion.", + "He underwent arthroscopic surgery under general anesthesia.", + "He was placed in the supine position.", + "Appropriate traction was applied on a traction table.", + "A lateral portal was created over the tip of the greater trochanter.", + "An anterolateral portal was placed between the lateral portal and the femoral artery and slightly distal to the transverse line.", + "An anterior portal was established at the inguinal groove slightly lateral to the femoral artery.", + "During arthroscopic evaluation of the central compartment, a cystic mass was identified between the transverse acetabular ligament and ligamentum teres.", + "The cyst was in continuity with the transverse acetabular ligament.", + "When the cyst was punctured, a blood-streaked yellowish viscous liquid was expelled.", + "The remaining cyst wall was resected in its entirety.", + "Histological examination revealed a glassy fibrous tissue wall without lining cells.", + "The diagnosis was confirmed as ganglion cyst.", + "Weight-bearing was permitted as tolerated after surgery.", + "The patient returned to recreational sports 6 months later.", + "No recurrence was detected on MRI at the 6-year follow-up postoperatively.", + "The patient had no complaints at the 6-year follow-up." + ], + "summary": "A 48-year-old man presented with the right groin pain after activity. A cystic lesion was found on magnetic resonance imaging. Under arthroscopic view, a cystic mass was identified between the TAL and ligamentum teres that discharged yellowish viscous liquid after puncture. The remaining lesion was resected in its entirety. A diagnosis of ganglion cyst was consistent with the histological findings. The patient has had no recurrence on magnetic resonance imaging as of 6 years postoperatively and had no complaints at the 6-year follow-up visit.", + "summary_subclaims": [ + "A 48-year-old man presented with the right groin pain after activity.", + "A cystic lesion was found on magnetic resonance imaging.", + "Under arthroscopic view, a cystic mass was identified between the TAL and ligamentum teres.", + "The mass discharged yellowish viscous liquid after puncture.", + "The remaining lesion was resected in its entirety.", + "A diagnosis of ganglion cyst was consistent with the histological findings.", + "The patient has had no recurrence on magnetic resonance imaging as of 6 years postoperatively.", + "The patient had no complaints at the 6-year follow-up visit." + ] + }, + { + "id": "multiclinsum_test_2182_en.txt", + "fulltext": "A 31-year-old patient, gravida 1, para 0, of Romanian origin, with no medical or surgical history, was followed in the Obstetrical Department at Montpellier University Hospital (France). She was not related to her husband. After discontinuing an oral contraceptive, she rapidly became pregnant with a singleton pregnancy with a normal first-trimester ultrasound scan and a low risk for Down syndrome prenatal screening (1/10,000) with a PAPP-A at 1.42 MoM, freeB-HCG at 1.07 MoM. She was referred to the prenatal diagnosis unit because of an unusual imaging of the fetal profile during second-trimester ultrasound imaging. A specialized ultrasound scan, performed at 25 weeks, confirmed the presence of a eutrophic male fetus with a single medial incisor and a narrow superior maxilla possibly ogival, without posterior palatal cleft . Fetal brain was normal with no sign of holoprosencephaly. Additionally, a flattened nasal sulcus and a flat profile were also mentioned (D). The nose aspect and medial central incisor were suggestive of nasal pyriform aperture stenosis.\nA fetal magnetic resonance imaging (MRI) was then performed at 30 weeks’ gestation, confirming upper jaw dysmorphism of triangular appearance, with a single median incisor and nasal pyriform aperture stenosis . The morphological assessment of the median line of the brain did not reveal any malformation, especially no holoprosencephaly, no hypertelorism, no choanal atresia, no cerebral lobes agenesis, and no microcephaly. After genetic counseling, an amniocentesis was performed retrieving a normal fetal karyotype (46XY) and a normal CGH array. In the absence of cerebral abnormality, the couple was informed not only of the good prognosis of the malformation but also for the need for a specialized consultation with a pediatric otolaryngologist/pediatric plastic surgeon. Depending on the size of the nasal pyriform aperture stenosis, the newborn could experience rapidly after birth or within a few weeks a respiratory distress syndrome, or, he could also tolerate very well the overall hypoplasia. The delivery was therefore organized in a type III maternity for postnatal close survey of the child.\nThe women delivered vaginally, at 39 weeks’ gestation of a baby boy weighing 3085 g (−0.8DS) measuring 46 cm (−1.7DS) with a head circumference of 33 cm (−1DS). He initially adapted very well in the delivery room with an Apgar score of 10 at 5 minutes, venous pH at 7.26, and arterial pH at 7.17. He did not experience immediate transient respiratory distress, and a routine neonatal intensive care unit survey for respiratory disorders was established. The newborn remained in spontaneous ventilation with an air humidifier and no desaturation below 90% was observed despite obstructive dyspnea associated with nasal pyriform aperture stenosis and mid-nasal stenosis confirmed by nasofibroscopy. Neurological clinical examination, child behavior, and paraclinic examinations were noted as normal, especially transfontanellar ultrasound, cerebral MRI screening on day 4, auditory screening, and funduscopic examination. The hormonal balance of the hypothalamic-pituitary axis was also normal.\nAt 5 days of life, a facial computed tomography (CT) scan confirmed a nasal pyriform aperture stenosis measured at a maximum transverse diameter of 5.4 mm, associated with an overall hypoplastic aspect of the anterior half of the nasal fossae, which had a triangular morphology. The nasal septum, although medial, had a thickened aspect (measured at 4.5 mm). Choanal atresia was not associated and the single median incisor diagnosed prenatally was confirmed . Due to good respiratory tolerance, the baby boy was discharged at home at 12 days of life.", + "fulltext_subclaims": [ + "The patient is a 31-year-old woman, gravida 1, para 0.", + "She is of Romanian origin.", + "She had no medical or surgical history.", + "She was followed in the Obstetrical Department at Montpellier University Hospital.", + "She was not related to her husband.", + "She discontinued an oral contraceptive.", + "She became pregnant with a singleton pregnancy.", + "The first-trimester ultrasound scan was normal.", + "The risk for Down syndrome prenatal screening was 1/10,000.", + "PAPP-A was 1.42 MoM.", + "FreeB-HCG was 1.07 MoM.", + "She was referred to the prenatal diagnosis unit due to unusual fetal profile imaging.", + "A specialized ultrasound scan was performed at 25 weeks.", + "The fetus was eutrophic and male.", + "The fetus had a single medial incisor.", + "The fetus had a narrow superior maxilla possibly ogival.", + "There was no posterior palatal cleft.", + "The fetal brain was normal.", + "There was no sign of holoprosencephaly.", + "A flattened nasal sulcus was mentioned.", + "A flat profile was mentioned.", + "The nose aspect and medial central incisor were suggestive of nasal pyriform aperture stenosis.", + "A fetal MRI was performed at 30 weeks.", + "The MRI confirmed upper jaw dysmorphism of triangular appearance.", + "The MRI confirmed a single median incisor.", + "The MRI confirmed nasal pyriform aperture stenosis.", + "The morphological assessment of the median line of the brain did not reveal any malformation.", + "There was no holoprosencephaly.", + "There was no hypertelorism.", + "There was no choanal atresia.", + "There was no cerebral lobes agenesis.", + "There was no microcephaly.", + "An amniocentesis was performed.", + "The fetal karyotype was 46XY.", + "The CGH array was normal.", + "The couple was informed of the good prognosis of the malformation.", + "The couple was informed of the need for a specialized consultation with a pediatric otolaryngologist/pediatric plastic surgeon.", + "The delivery was organized in a type III maternity.", + "The woman delivered vaginally at 39 weeks.", + "The baby boy weighed 3085 g.", + "The baby boy measured 46 cm.", + "The baby boy had a head circumference of 33 cm.", + "The Apgar score was 10 at 5 minutes.", + "Venous pH was 7.26.", + "Arterial pH was 7.17.", + "The newborn did not experience immediate transient respiratory distress.", + "A routine neonatal intensive care unit survey for respiratory disorders was established.", + "The newborn remained in spontaneous ventilation.", + "No desaturation below 90% was observed.", + "Nasal pyriform aperture stenosis and mid-nasal stenosis were confirmed by nasofibroscopy.", + "Neurological clinical examination was normal.", + "Child behavior was normal.", + "Paraclinic examinations were noted as normal.", + "Transfontanellar ultrasound was normal.", + "Cerebral MRI screening on day 4 was normal.", + "Auditory screening was normal.", + "Funduscopic examination was normal.", + "The hormonal balance of the hypothalamic-pituitary axis was normal.", + "A facial CT scan was performed at 5 days of life.", + "The CT scan confirmed nasal pyriform aperture stenosis measured at a maximum transverse diameter of 5.4 mm.", + "The CT scan confirmed an overall hypoplastic aspect of the anterior half of the nasal fossae.", + "The nasal fossae had a triangular morphology.", + "The nasal septum had a thickened aspect measured at 4.5 mm.", + "Choanal atresia was not associated.", + "The single median incisor diagnosed prenatally was confirmed.", + "The baby boy was discharged at home at 12 days of life." + ], + "summary": "We report the first prenatal ultrasound description of a 31-year-old patient, gravida 1, para 0, whose male fetus was diagnosed at 25 weeks' gestation with a single median incisor suggestive of nasal pyriform aperture stenosis in Montpellier University Hospital (France). A fetal magnetic resonance imaging (MRI) performed at 30 weeks' gestation retrieved no intracranial midline cerebral anomalies and confirm nasal pyriform aperture stenosis suspicion. Amniocentesis, performed at 31 weeks, found a normal fetal karyotype (46XY) and a normal comparative genomic hybridization (CGH) array. After term vaginal delivery, clinical and radiological examination confirmed the diagnosis of an isolated single median maxillary central incisor linked to nasal pyriform aperture stenosis.", + "summary_subclaims": [ + "The patient was 31 years old.", + "The patient was gravida 1 and para 0.", + "The fetus was male.", + "The fetus was diagnosed at 25 weeks' gestation with a single median incisor.", + "The diagnosis was suggestive of nasal pyriform aperture stenosis.", + "The diagnosis was made at Montpellier University Hospital in France.", + "A fetal MRI was performed at 30 weeks' gestation.", + "The fetal MRI retrieved no intracranial midline cerebral anomalies.", + "The fetal MRI confirmed the suspicion of nasal pyriform aperture stenosis.", + "Amniocentesis was performed at 31 weeks.", + "The fetal karyotype was 46XY.", + "The CGH array was normal.", + "The fetus was delivered vaginally at term.", + "Clinical and radiological examination confirmed the diagnosis of an isolated single median maxillary central incisor.", + "The single median maxillary central incisor was linked to nasal pyriform aperture stenosis." + ] + }, + { + "id": "multiclinsum_test_3175_en.txt", + "fulltext": "An 11-year-old male came to our hospital with a complaint of bilateral nasal bleeding of 1 day duration, which was of about 4 times, and it was massive as claimed by the family. He also has had associated history of skin rash which was noticed a day prior to the onset of nasal bleeding.\n\nOn further asking, the patient has had history of loss of appetite and significant but unquantified weight loss of one month duration but no history of fever or cough. He has no history of bleeding diseases, connective tissue disorders, autoimmune disorders, or cancer in himself or in his family. All vital signs were normal at the time of presentation, but there was a dry clot in the nostril bilaterally and no symptoms of anemia. A chest examination revealed scattered inspiratory crackles on both sides of the upper lung zone. Organomegaly, there was nothing. A petechial rash covered the chest and rear sides of the body, including the upper extremities.\n\nExcept for isolated thrombocytopenia, a complete blood count and serum chemistry, including the reticulocyte count, were unremarkable. A peripheral blood smear revealed isolated severe thrombocytopenia with normal blood cell morphology. Autoimmune screening (ANA, Coombs test), coagulation profile, viral screening including the COVID-19 test, blood cultures, urine cultures, were all non-revealing. The rate of erythrocyte sedimentation (ESR) was 70 mm/hr, which is suggestive of MTB. A smear for acid-fast bacilli was negative, but Gene expert from the sputum detected MTB with rifampicin sensitivity.\n\nThe ultimate outcome of the chest X-ray revealed bilateral diffusely dispersed nodular opacities all over the lung fields, which were commented on by three different radiologists.\n\nWith a presumptive diagnosis of immune thrombocytopenic purpura (ITP), the patient was hospitalised and began therapy with oral prednisolone 20 mg twice a day.\n\nHe was then managed with antituberculosis (ATT) RHZ (75/50/150) 4 tablets, and E100 mg (R stands for Rifampicin, H for Isoniazid, Z for Pyrazinamide, and E for Ethambutol in this order). Four tablets as per the national guideline, which was started after 1 week of admission because of late isolation of TB.\n\nPrednisolone 2mg/kg/day, ie 20 mg po bid (tapered over six weeks and stopped), and there were no reported problems of initial complaints after withdrawing the prednisolone.\n\nHe was transfused with Platelet 20 mg/kg, ie 400 mg, with post-transfusion CBC of almost the same, supporting the diagnosis of ITP.\n\nThis patient was discharged after 2 weeks of hospitalization, being taking ATT and Prednisolone, with the latest platelet count of 44,000*109, with appointment after 2 weeks or to come early if there are any complications. Fortunately, there were no complications related to the disease/or treatment, and on the day of appointment (after a total duration of 1 month of treatment and 31 days of the complaint), repeated CBC was done, and it showed Platelet count of 59,000*10*9 and the organ function test in search of ATT-related toxicities were also all in the normal range. The patient was again appointed after 2 months, and on return, the Platelet count was raised to 118,000*109 which is still below the normal value. Prednisolone was tapered over 6 weeks and stopped. After the total six months of therapy with ATT, platelet counts (204* 109) were became in the normal range after being successfully increased amid follow-up, and ATT was stopped as per the national guideline.", + "fulltext_subclaims": [ + "The patient is an 11-year-old male.", + "He had bilateral nasal bleeding of 1 day duration.", + "The nasal bleeding occurred about 4 times.", + "The nasal bleeding was described as massive by the family.", + "He had a history of skin rash noticed a day prior to the onset of nasal bleeding.", + "He had a history of loss of appetite.", + "He had significant but unquantified weight loss over one month.", + "He had no history of fever.", + "He had no history of cough.", + "He had no history of bleeding diseases.", + "He had no history of connective tissue disorders.", + "He had no history of autoimmune disorders.", + "He had no history of cancer in himself or his family.", + "All vital signs were normal at the time of presentation.", + "There was a dry clot in the nostril bilaterally.", + "There were no symptoms of anemia.", + "A chest examination revealed scattered inspiratory crackles on both sides of the upper lung zone.", + "A petechial rash covered the chest and rear sides of the body, including the upper extremities.", + "A complete blood count showed isolated thrombocytopenia.", + "A peripheral blood smear revealed isolated severe thrombocytopenia with normal blood cell morphology.", + "Autoimmune screening (ANA, Coombs test) was non-revealing.", + "Coagulation profile was non-revealing.", + "Viral screening including the COVID-19 test was non-revealing.", + "Blood cultures were non-revealing.", + "Urine cultures were non-revealing.", + "The rate of erythrocyte sedimentation (ESR) was 70 mm/hr.", + "A smear for acid-fast bacilli was negative.", + "Gene expert from the sputum detected MTB with rifampicin sensitivity.", + "The chest X-ray showed bilateral diffusely dispersed nodular opacities all over the lung fields.", + "The patient was hospitalised with a presumptive diagnosis of immune thrombocytopenic purpura (ITP).", + "The patient began therapy with oral prednisolone 20 mg twice a day.", + "He was managed with antituberculosis (ATT) RHZ (75/50/150) 4 tablets.", + "The ATT was started after 1 week of admission.", + "He was transfused with Platelet 20 mg/kg, ie 400 mg.", + "The post-transfusion CBC showed almost the same platelet count.", + "He was discharged after 2 weeks of hospitalization.", + "On the day of appointment after a total duration of 1 month of treatment and 31 days of the complaint, repeated CBC showed Platelet count of 59,000*10*9.", + "The organ function test in search of ATT-related toxicities was all in the normal range.", + "On return after 2 months, the Platelet count was 118,000*109.", + "After the total six months of therapy with ATT, platelet counts were 204* 109.", + "ATT was stopped as per the national guideline." + ], + "summary": "We discuss a case of an 11-year-old male adolescent who came with epistaxis and petechial rash lasting one day, as well as severe thrombocytopenia. Following the clinical diagnosis of ITP, the patient was started on prednisone, transfused with platelets, and later started on antituberculosis (ATT) after confirmation of tuberculosis. The patient had a satisfactory response during the course of treatment, and the platelet level was fully recovered after 6 months.", + "summary_subclaims": [ + "The patient is an 11-year-old male adolescent.", + "The patient had epistaxis.", + "The patient had a petechial rash.", + "The symptoms lasted one day.", + "The patient had severe thrombocytopenia.", + "The clinical diagnosis was ITP.", + "The patient was started on prednisone.", + "The patient was transfused with platelets.", + "The patient was started on antituberculosis (ATT) after confirmation of tuberculosis.", + "The patient had a satisfactory response during the course of treatment.", + "The platelet level was fully recovered after 6 months." + ] + }, + { + "id": "multiclinsum_test_3080_en.txt", + "fulltext": "Medical history: A patient with a history of type 2 diabetes mellitus, dyslipidemia, and hypertension was referred to dermatology for a 1-month pruritic, scaly eruption of the palms and soles unresponsive to topical steroids. Her medications included lisinopril, metformin, atorvastatin, calcium carbonate, and vitamin D. Examination revealed well-defined, irregularly shaped erythematous and scaly plaques on the palms and soles without nail involvement. Laboratory investigation including complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein, and lactate dehydrogenase yielded normal results. Histopathological examination of the right sole punch biopsy specimen showed compact orthokeratosis and mild superficial perivascular lymphocyte infiltrate with focal exocytosis predominantly at the basal layer, and mild lymphocytic cytologic atypia including nuclear enlargement, hyperchromasia and irregular nuclear contour. Immunophenotyping studies showed a predominance of CD3-positive T cells with a CD4 to CD8 ratio of 1:1 and a preserved but decreased CD7 expression. The findings of palmoplantar keratoderma, low-grade lymphoid atypia, basilar lymphocyte exocytosis, and the phenotypic profile illustrated by a decline in CD7 expression collectively supported the diagnosis of keratoderma-like T-cell dyscrasia. Two weeks following atorvastatin disconsolation and the use of mid-potency topical steroids, the patient reported an 80% improvement in pruritus and reduced erythema and scaling of the palms and soles within 2 weeks. At the 6-month follow-up, complete resolution of the keratoderma and pruritus was observed.", + "fulltext_subclaims": [ + "The patient has a history of type 2 diabetes mellitus.", + "The patient has a history of dyslipidemia.", + "The patient has a history of hypertension.", + "The patient had a 1-month pruritic, scaly eruption of the palms and soles.", + "The eruption was unresponsive to topical steroids.", + "Her medications included lisinopril.", + "Her medications included metformin.", + "Her medications included atorvastatin.", + "Her medications included calcium carbonate.", + "Her medications included vitamin D.", + "Examination revealed well-defined, irregularly shaped erythematous and scaly plaques on the palms and soles.", + "There was no nail involvement.", + "Laboratory investigation including complete blood count with differential yielded normal results.", + "Erythrocyte sedimentation rate yielded normal results.", + "C-reactive protein yielded normal results.", + "Lactate dehydrogenase yielded normal results.", + "Histopathological examination showed compact orthokeratosis.", + "Histopathological examination showed mild superficial perivascular lymphocyte infiltrate with focal exocytosis predominantly at the basal layer.", + "Histopathological examination showed mild lymphocytic cytologic atypia including nuclear enlargement, hyperchromasia and irregular nuclear contour.", + "Immunophenotyping studies showed a predominance of CD3-positive T cells.", + "Immunophenotyping studies showed a CD4 to CD8 ratio of 1:1.", + "Immunophenotyping studies showed a preserved but decreased CD7 expression.", + "The findings supported the diagnosis of keratoderma-like T-cell dyscrasia.", + "Two weeks following atorvastatin discontinuation and the use of mid-potency topical steroids, the patient reported an 80% improvement in pruritus.", + "Two weeks following atorvastatin discontinuation and the use of mid-potency topical steroids, the patient reported reduced erythema and scaling of the palms and soles.", + "At the 6-month follow-up, complete resolution of the keratoderma and pruritus was observed." + ], + "summary": "A patient presented with a pruritic, scaly eruption on her palms and soles unresponsive to topical steroids for 1 month. Histopathological examination revealed compact orthokeratosis, mild lymphocytic infiltrate with focal exocytosis, and atypical lymphocytes. Immunophenotyping demonstrated a predominance of CD3+ T cells with a 1:1 CD4/CD8 ratio and reduced CD7 expression. The clinical presentation, histopathology, and immunophenotype supported a diagnosis of statin-induced CTCD.", + "summary_subclaims": [ + "The patient had a pruritic, scaly eruption on her palms and soles.", + "The eruption was unresponsive to topical steroids for 1 month.", + "Histopathological examination revealed compact orthokeratosis.", + "Histopathological examination showed a mild lymphocytic infiltrate with focal exocytosis.", + "Atypical lymphocytes were noted on histopathological examination.", + "Immunophenotyping demonstrated a predominance of CD3+ T cells.", + "The CD4/CD8 ratio was 1:1.", + "CD7 expression was reduced.", + "The clinical presentation, histopathology, and immunophenotype supported a diagnosis of statin-induced CTCD." + ] + }, + { + "id": "multiclinsum_test_731_en.txt", + "fulltext": "A 37-year-old woman (Body-Mass Index: 23.62 kg/m2) was attending the Ingenes Institute in México City for secondary infertility.\nThe patient has been trying to get pregnant for 24 mo with negative results, using only natural methods to conceive. We proposed an in vitro fertilization (IVF) protocol, complimented with pre-implantation genetic diagnosis (PGD).\nThree years prior to her attending Ingenes, she had one previous pregnancy, which was resolved by a cesarean section after placental detachment. Afterward, she presented abnormal uterine bleeding with bloody or brown vaginal discharge, severe pelvic pain, dyspareunia, and urinary discomfort eight months after the cesarean.\nShe had no other medical complications and was not taking any medications. No causes of male infertility were found in her partner.\nThe patient underwent a standard course of controlled ovarian stimulation (Depot GnRH agonist, Cetrotide 0.25 mg daily dose, Merck, Darmstadt, Germany). In the immediate days after controlled ovarian stimulation started (9 d), we observed the formation of hydrometra. The patient was given a single dose of Triptorelin (0.2 mg; Gospeptyl daily Ferring Pharmaceuticals, Saint-Prex, Switzerland). Stimulation was prolonged until the diameter of leading follicles was > 18 mm (18-22 mm). Then, recombinant human chorionic gonadotropin (hCG) (Choragon 1000 IU, Ferring Pharmaceuticals, Saint-Prex, Switzerland) was administered, and oocytes were retrieved after 36 h with ultrasound guidance. All 14-18 mm follicles were aspirated, and 20 ova were collected. It was decided to proceed to fertilization and culture. The ova were fertilized by intracytoplasmic sperm injection, and six embryos developed (2AB, 2BB, and 2BC Inner cell mass/Trophoblast quality). With the embryos that reached day 5, a trophectoderm biopsy was collected for PGD, and then the embryos were frozen. After PGD, four euploid embryos were considered for implantation; however, it was decided to postpone implantation for one month to allow for endometrial preparation.\nThe endometrial preparation was carried out with the application of an in situ agonist prior to the Luteal phase (Triptorelin 3.75 mg, Gonspeptyl daily, Ferring) and transdermal application of 17-β-estradiol (Evorel 50). On day 10 of endometrial preparation, the formation of hydrometra was again evident, so it was decided to cancel the endometrial preparation cycle and perform an endometrial cavity evaluation-closing of any ostia by hysteroscopy with the suspicion of a possible hydrosalpinx. The proximal closing of tubal ostia was performed without any complications, finding a normal cavity. A second endometrial preparation was performed with the same protocol. On day 10 of the endometrial preparation, the formation of hydrometra was again evident, so we decided to cancel the cycle, and treat the patient with progestin (Utrogestan, 100 mg every 12 h, 5 d, SEID, Barcelona, Spain). A new endometrial preparation with estradiol valerate (Primogyn, Bayer Health) was tried using 6 mg/d as the maximum dose, and on the 13th d of preparation, the hydrometra formation was again evident.\nNone.\nA transvaginal ultrasound was performed, and in addition to hydrometra, the presence of an isthmocele was located at the anterior wall of the uterine isthmus. Its base was 6.6 mm and height was 6.1 mm, indicating the presence of a second-degree isthmocele . Re-evaluation of a previous hysteroscopy video was performed, where a thorough evaluation of the defect area was not performed, probably due to the absence of characteristic symptoms.", + "fulltext_subclaims": [ + "The patient is a 37-year-old woman with a body-mass index of 23.62 kg/m2.", + "She was attending the Ingenes Institute in México City for secondary infertility.", + "She had been trying to get pregnant for 24 months with natural methods.", + "She had one previous pregnancy, which was resolved by a cesarean section after placental detachment.", + "After the cesarean, she presented abnormal uterine bleeding with bloody or brown vaginal discharge.", + "She had severe pelvic pain, dyspareunia, and urinary discomfort eight months after the cesarean.", + "No causes of male infertility were found in her partner.", + "She underwent a standard course of controlled ovarian stimulation.", + "During controlled ovarian stimulation, hydrometra was observed.", + "She was given a single dose of Triptorelin (0.2 mg).", + "Stimulation was prolonged until the diameter of leading follicles was > 18 mm.", + "Recombinant human chorionic gonadotropin (Choragon 1000 IU) was administered.", + "Oocytes were retrieved after 36 h with ultrasound guidance.", + "All 14-18 mm follicles were aspirated, and 20 ova were collected.", + "The ova were fertilized by intracytoplasmic sperm injection.", + "Six embryos developed (2AB, 2BB, and 2BC Inner cell mass/Trophoblast quality).", + "A trophectoderm biopsy was collected for PGD.", + "After PGD, four euploid embryos were considered for implantation.", + "It was decided to postpone implantation for one month.", + "Endometrial preparation was carried out with an in situ agonist prior to the Luteal phase.", + "Transdermal application of 17-β-estradiol (Evorel 50) was used.", + "On day 10 of endometrial preparation, the formation of hydrometra was again evident.", + "It was decided to cancel the endometrial preparation cycle.", + "A hysteroscopy was performed with the suspicion of a possible hydrosalpinx.", + "The proximal closing of tubal ostia was performed without any complications.", + "A second endometrial preparation was performed with the same protocol.", + "On day 10 of the second endometrial preparation, the formation of hydrometra was again evident.", + "The patient was treated with progestin (Utrogestan, 100 mg every 12 h, 5 d).", + "A new endometrial preparation with estradiol valerate (Primogyn) was tried using 6 mg/d as the maximum dose.", + "On the 13th day of preparation, the hydrometra formation was again evident.", + "A transvaginal ultrasound was performed.", + "In addition to hydrometra, the presence of an isthmocele was located at the anterior wall of the uterine isthmus.", + "The isthmocele had a base of 6.6 mm and height of 6.1 mm.", + "The isthmocele was classified as second-degree.", + "A re-evaluation of a previous hysteroscopy video was performed.", + "A thorough evaluation of the defect area was not performed in the previous hysteroscopy.", + "The absence of characteristic symptoms likely contributed to the lack of evaluation in the previous hysteroscopy." + ], + "summary": "The patient underwent hysteroscopic surgery, which successfully resolved the isthmocele as well as the hydrometra. Afterward, two high-quality, euploid embryos, determined by morphological assessment and pre-implantation genetic diagnostic testing, were transferred. This resulted in uterine pregnancy, as determined by serum β-human chorionic gonadotropin levels on day 14 (180 mU/mL) and ultrasound-confirmed presence of a gestational sac with a positive embryocardia at week 6. The pregnancy reached 36 wk without any complications, and the product was born in good health. We report a successful isthmocele treatment in a patient with secondary infertility, in which the isthmocele was the cause of persistent hydrometra.", + "summary_subclaims": [ + "The patient underwent hysteroscopic surgery.", + "The surgery successfully resolved the isthmocele.", + "The surgery successfully resolved the hydrometra.", + "Two high-quality, euploid embryos were transferred.", + "The embryos were determined by morphological assessment and pre-implantation genetic diagnostic testing.", + "The transfer resulted in uterine pregnancy.", + "Serum β-human chorionic gonadotropin levels on day 14 were 180 mU/mL.", + "Ultrasound confirmed the presence of a gestational sac with a positive embryocardia at week 6.", + "The pregnancy reached 36 wk without any complications.", + "The product was born in good health.", + "We report a successful isthmocele treatment in a patient with secondary infertility.", + "The isthmocele was the cause of persistent hydrometra." + ] + }, + { + "id": "multiclinsum_test_2225_en.txt", + "fulltext": "A 75-year-old man was transferred to our emergency department for examination of abdominal pain and frequent vomiting. His medical history records reported hypertension, diabetes, mild dyslipidemia, and gastric cancer that was managed with a distal gastrectomy procedure 2 years prior to his admission to our hospital. Reconstruction by Billroth I anastomosis was performed on the stomach. The patient's vital signs were as follows: Glasgow Coma Scale score, E4V5M6; temperature, 36.6°C; blood pressure, 139/103 mmHg; heart rate, 108 b.p.m.; respiratory rate, 25 breaths/min; and oxygen saturation, 94%.\nThe physical examination revealed that his abdomen was flat and soft, with sensitivity in the midline but no recurrent pain. His symptoms included nausea, regurgitation, and hematemesis, while jaundice and pallor were not detected.\nComplete blood count revealed the following: white blood cells, 14.4 × 109/L; hemoglobin, 193 g/L; and platelets, 161 × 109/L. The serum laboratory tests were all within the normal range except: total amylase, 1,363 IU/L; blood urea nitrogen, 44.9 mg/dL; creatinine, 2.25 mg/dL; glucose, 453 mg/dL; hemoglobin A1c, 7.6%; and C-reactive protein, 3.13 mg/dL. Total cholesterol, low-density lipoprotein cholesterol, triglycerides, and total bilirubin levels were also normal.\nAbdominal computed tomography (CT) indicated enlarged pancreas with fluid retention and a bezoar with air component in the duodenum, with the absence of stones in the gallbladder and common bile duct . Following the physical inspection, we undertook esophagogastroduodenoscopy (EGD) to identify the cause of frequent vomiting, hematemesis, and duodenal obstruction. We detected only mild bleeding caused by reflux esophagitis and a bezoar that had obstructed the duodenum.\nThe patient's consumption of alcohol was low with no evidence of trauma, infections, or medications. Therefore, we concluded that the bezoar was the main cause of acute pancreatitis.\nIn the absence of elevated bilirubin levels, we decided to follow a conservative treatment strategy, assuming that the common bile duct was impartially obstructed. The patient was admitted to the intensive care unit (ICU) where intravenous fluids were administered, and his urine output was monitored. It was difficult to maintain urine output, and he was started on ventilatory management because he developed respiratory failure on day 3 of hospitalization. The patient had gone into shock, which persisted. Vasopressors were administered. Antimicrobials were started because bilirubin levels were elevated, which can result in complications like acute cholangitis. Despite supportive care, his symptoms did not improve, and bilirubin levels continued to increase. Abdominal contrast-enhanced CT carried out on day 3 revealed the presence of residual duodenal bezoar and obstruction of the common bile duct . He had been admitted with acute pancreatitis due to papillary obstruction, but the bilirubin level was speculated to have risen over time. We reconsidered the papillary obstruction as the cause of the acute pancreatitis. We decided to remove the bezoar and open papillae. He presented with coagulopathy and poor clinical condition, and surgery was considered an unsafe treatment option. Therefore, we attempted to dissect the bezoar by undertaking EGD; forceps were used to crush the bezoar and attempt maximum removal. However, the bezoar was large and hard, and could not be removed in a single EGD. The procedure was repeated three times, on days 6, 7, and 9, to dissect and remove the bezoars . In a previous case, duodenal diverticulum had been noted as a cause of the bezoar, but no diverticulum was found in this case. Duodenal papillae unclogged and the bilirubin levels declined. Chemical analysis of the stone revealed that the bezoars mainly consisted of calcium oxalate (>98%).\nFollowing the bezoars' removal, the patient's clinical condition gradually improved, and he was extubated on day 7. On day 8 the patient left the ICU and on day 31 he was discharged from the hospital with no complications. A 6-month follow-up revealed no recurrence of the symptoms.", + "fulltext_subclaims": [ + "The patient was a 75-year-old man.", + "The patient was transferred to the emergency department for abdominal pain and frequent vomiting.", + "The patient had a history of gastric cancer managed with a distal gastrectomy 2 years prior.", + "The reconstruction was performed by Billroth I anastomosis.", + "The patient's Glasgow Coma Scale score was E4V5M6.", + "The patient's blood pressure was 139/103 mmHg.", + "The patient's heart rate was 108 b.p.m.", + "The patient's oxygen saturation was 94%.", + "The physical examination revealed sensitivity in the midline.", + "The patient had symptoms of nausea, regurgitation, and hematemesis.", + "Jaundice was not detected.", + "White blood cell count was 14.4 × 109/L.", + "Hemoglobin was 193 g/L.", + "Platelets were 161 × 109/L.", + "Total amylase was 1,363 IU/L.", + "Blood urea nitrogen was 44.9 mg/dL.", + "Creatinine was 2.25 mg/dL.", + "Glucose was 453 mg/dL.", + "Hemoglobin A1c was 7.6%.", + "C-reactive protein was 3.13 mg/dL.", + "Abdominal CT showed an enlarged pancreas with fluid retention.", + "Abdominal CT showed a bezoar with air component in the duodenum.", + "Abdominal CT showed no stones in the gallbladder and common bile duct.", + "EGD was performed to identify the cause of frequent vomiting, hematemesis, and duodenal obstruction.", + "EGD detected mild bleeding caused by reflux esophagitis.", + "EGD detected a bezoar that had obstructed the duodenum.", + "The patient's alcohol consumption was low.", + "There was no evidence of trauma, infections, or medications.", + "The bezoar was concluded to be the main cause of acute pancreatitis.", + "The patient was admitted to the ICU.", + "Intravenous fluids were administered.", + "Urine output was monitored.", + "It was difficult to maintain urine output.", + "The patient developed respiratory failure on day 3 of hospitalization.", + "The patient was started on ventilatory management.", + "The patient had gone into shock.", + "Vasopressors were administered.", + "Antimicrobials were started because bilirubin levels were elevated.", + "Bilirubin levels continued to increase.", + "Abdominal contrast-enhanced CT on day 3 revealed residual duodenal bezoar.", + "Abdominal contrast-enhanced CT on day 3 revealed obstruction of the common bile duct.", + "The bezoar was speculated to have caused the rise in bilirubin levels.", + "The papillary obstruction was reconsidered as the cause of acute pancreatitis.", + "The decision was made to remove the bezoar and open papillae.", + "Surgery was considered an unsafe treatment option.", + "EGD was attempted to dissect the bezoar.", + "Forceps were used to crush the bezoar.", + "The bezoar was large and hard.", + "The bezoar could not be removed in a single EGD.", + "The procedure was repeated three times, on days 6, 7, and 9.", + "Duodenal papillae were unclogged.", + "Bilirubin levels declined.", + "Chemical analysis of the stone revealed that the bezoars mainly consisted of calcium oxalate (>98%).", + "The patient was extubated on day 7.", + "The patient left the ICU on day 8.", + "The patient was discharged from the hospital on day 31.", + "A 6-month follow-up revealed no recurrence of the symptoms." + ], + "summary": "A 75-year-old man experiencing abdominal pain and frequent vomiting was transferred to our hospital. His medical records presented history of diabetes, hypertension, dyslipidemia, and gastric cancer surgery. Computed tomography of the abdomen indicated duodenal dilatation, enlarged pancreas, and fluid retention, with no bile duct stones present. Minor bleeding and duodenal bezoar were endoscopically detected with esophagogastroduodenoscopy (EGD). He was diagnosed with severe acute pancreatitis caused by a bezoar and admitted to the intensive care unit. The duodenal bezoar was dissected and removed with three repetitions of EGD, and the patient was discharged without any complications.", + "summary_subclaims": [ + "A 75-year-old man was transferred to our hospital.", + "The man was experiencing abdominal pain.", + "The man was experiencing frequent vomiting.", + "Computed tomography of the abdomen indicated duodenal dilatation.", + "Computed tomography of the abdomen indicated an enlarged pancreas.", + "Computed tomography of the abdomen indicated fluid retention.", + "Computed tomography of the abdomen showed no bile duct stones.", + "Minor bleeding was endoscopically detected with esophagogastroduodenoscopy.", + "A duodenal bezoar was endoscopically detected with esophagogastroduodenoscopy.", + "He was diagnosed with severe acute pancreatitis.", + "The diagnosis was caused by a bezoar.", + "The patient was admitted to the intensive care unit.", + "The duodenal bezoar was dissected and removed with three repetitions of EGD.", + "The patient was discharged without any complications." + ] + }, + { + "id": "multiclinsum_test_1619_en.txt", + "fulltext": "A 34-year-old woman presented to the emergency department (ED) with progressive leg swelling. Thorough laboratory testing as an outpatient and in the ED was unrevealing. To evaluate further the causes of her dyspnea and edema, we performed a point-of-care ultrasound (POCUS) of the heart, lungs, and abdomen. While evaluating for evidence of ascites, a large mass with anechoic center was identified in the right upper quadrant (, and ). This prompted computed tomography (CT) of the abdomen and pelvis, which confirmed a 7.9 × 9.1 × 8.7 centimeter mass arising from the right posterior liver, extending into the inferior vena cava with an associated near-occlusive tumor thrombus . During admission, a biopsy was performed revealing adrenocortical carcinoma (ACC).", + "fulltext_subclaims": [ + "The patient is a 34-year-old woman.", + "She presented to the emergency department with progressive leg swelling.", + "Thorough laboratory testing as an outpatient and in the ED was unrevealing.", + "A point-of-care ultrasound of the heart, lungs, and abdomen was performed.", + "A large mass with an anechoic center was identified in the right upper quadrant.", + "Computed tomography of the abdomen and pelvis confirmed a 7.9 × 9.1 × 8.7 centimeter mass.", + "The mass arose from the right posterior liver.", + "The mass extended into the inferior vena cava.", + "There was an associated near-occlusive tumor thrombus.", + "A biopsy was performed during admission.", + "The biopsy revealed adrenocortical carcinoma." + ], + "summary": "A 34-year-old woman presented to the emergency department with bilateral lower extremity edema and shortness of breath. She had been seen by her primary care provider. Lab work and a follow-up with endocrinology had been unrevealing. Using point-of-care ultrasound we identified a cystic mass in the right upper quadrant prompting further imaging.", + "summary_subclaims": [ + "A 34-year-old woman presented to the emergency department with bilateral lower extremity edema and shortness of breath.", + "She had been seen by her primary care provider.", + "Lab work and a follow-up with endocrinology had been unrevealing.", + "Using point-of-care ultrasound we identified a cystic mass in the right upper quadrant.", + "The cystic mass in the right upper quadrant prompted further imaging." + ] + }, + { + "id": "multiclinsum_test_2394_en.txt", + "fulltext": "A 14-year-old boy attended a local hospital for ankylosing spondylitis. Chest radiography showed an enhanced circular-density shadow near the left mediastinum, which intersected with the mediastinum at an obtuse angle; the base was close to the mediastinum, the outer edge clear and smooth, and the mass density even. A benign lesion was considered. Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment.\nThe patient had no previous symptoms.\nThe patient had no major illness before, and mandatory spondylitis was discovered this time because of his left hip pain.\nThe patient had no previous symptoms.\nThe results of the physical examination were normal.\nBlood analysis and the blood biochemistries, as well as urine analysis, were all normal. Electrocardiogram and arterial blood gas were also normal.\nEnhanced chest CT suggested irregular soft tissue density above the left aortic arch with a clear boundary, about 5.5 cm × 3.2 cm × 2.8 cm in size .", + "fulltext_subclaims": [ + "A 14-year-old boy attended a local hospital for ankylosing spondylitis.", + "Chest radiography showed an enhanced circular-density shadow near the left mediastinum.", + "The shadow intersected with the mediastinum at an obtuse angle.", + "The base was close to the mediastinum.", + "The outer edge was clear and smooth.", + "The mass density was even.", + "A benign lesion was considered.", + "Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment.", + "The patient had no previous symptoms.", + "The patient had no major illness before.", + "Mandatory spondylitis was discovered this time because of his left hip pain.", + "The results of the physical examination were normal.", + "Blood analysis and the blood biochemistries, as well as urine analysis, were all normal.", + "Electrocardiogram and arterial blood gas were also normal.", + "Enhanced chest CT suggested irregular soft tissue density above the left aortic arch.", + "The mass had a clear boundary.", + "The mass was about 5.5 cm × 3.2 cm × 2.8 cm in size." + ], + "summary": "A 14-year-old boy attended a local hospital for ankylosing spondylitis. Chest radiography showed an enhanced circular-density shadow near the left mediastinum. The patient had no chest symptoms and the physical examination was normal. Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment. During surgery, a left pericardial defect was observed. The bronchogenic cyst was removed by thoracoscopic surgery, but the pericardial defect remained untreated, and a satisfactory outcome was achieved after the operation. The patient was diagnosed with a mediastinal tumor. The pathological diagnosis of the tumor was a bronchogenic cyst.", + "summary_subclaims": [ + "A 14-year-old boy attended a local hospital for ankylosing spondylitis.", + "Chest radiography showed an enhanced circular-density shadow near the left mediastinum.", + "The patient had no chest symptoms.", + "The physical examination was normal.", + "Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment.", + "During surgery, a left pericardial defect was observed.", + "The bronchogenic cyst was removed by thoracoscopic surgery.", + "The pericardial defect remained untreated.", + "A satisfactory outcome was achieved after the operation.", + "The patient was diagnosed with a mediastinal tumor.", + "The pathological diagnosis of the tumor was a bronchogenic cyst." + ] + }, + { + "id": "multiclinsum_test_214_en.txt", + "fulltext": "A 67-year-old male patient was admitted in our department due to a mass in front of the ankle joint for 23 years.\nIn 1998, his right foot was accidentally injured by a brick that fell from a height. He developed pain and swelling in the front of his right foot and calf. He went to a local hospital and was diagnosed with a soft tissue infection. The patient developed a hard mass on the right ankle 3 mo after the injury, about the size of an egg, with no limited ankle joint movement. He then went to the local hospital for treatment and surgery was suggested. The patient did not undergo surgery as the mass did not cause obvious pain and did not affect his joint function.\nThree years ago, the patient experienced an accidental sprain of the right ankle with ankle immobility, and was admitted to our department for surgical treatment.\nThe patient had no remarkable medical history, no history of hypertension, diabetes, hepatitis, tuberculosis, drugs, or food allergies.\nA lump was seen in front of the dorsum of the right foot and the middle and lower part of the calf, which was obvious on the right dorsum; the right calf was slightly swollen, the skin was slightly translucent, there was no obvious tenderness, and the skin temperature was not elevated. The mass on the right dorsum was approximately 6 cm × 7 cmin size and non-movable, with a hard texture, unclear boundary, unsmooth surface, no obvious tenderness, no obvious boundary with surrounding tissues, and there was no right ankle joint movement. The blood supply, sensation and movement of the extremity were good.\nRoutine blood tests showed that C-reactive protein, erythrocyte sedimentation rate, alkaline phosphatase, blood sugar, and blood trioxypurine were normal.\nX-ray showed a bone mass in front of the right tibia. Computed tomography (CT) showed multiple patchy bone masses with uneven bone density in front of the upper segment of the right tibia and the dorsum of the right foot. The edge of the right ankle joint was osteosclerotic with adequate joint space.", + "fulltext_subclaims": [ + "A 67-year-old male patient was admitted due to a mass in front of the ankle joint for 23 years.", + "In 1998, his right foot was accidentally injured by a brick that fell from a height.", + "He developed pain and swelling in the front of his right foot and calf.", + "He was diagnosed with a soft tissue infection.", + "A hard mass on the right ankle developed 3 mo after the injury, about the size of an egg.", + "The mass did not cause limited ankle joint movement.", + "Surgery was suggested.", + "The patient did not undergo surgery.", + "Three years ago, the patient experienced an accidental sprain of the right ankle with ankle immobility.", + "The patient was admitted to our department for surgical treatment.", + "The patient had no history of hypertension, diabetes, hepatitis, tuberculosis, drugs, or food allergies.", + "A lump was seen in front of the dorsum of the right foot and the middle and lower part of the calf.", + "The right calf was slightly swollen.", + "The skin was slightly translucent.", + "There was no obvious tenderness.", + "The skin temperature was not elevated.", + "The mass on the right dorsum was approximately 6 cm × 7 cm in size.", + "The mass was non-movable.", + "The mass had a hard texture.", + "The mass had an unclear boundary.", + "The mass had an unsmooth surface.", + "There was no obvious boundary with surrounding tissues.", + "There was no right ankle joint movement.", + "The blood supply, sensation, and movement of the extremity were good.", + "Routine blood tests showed normal C-reactive protein.", + "Routine blood tests showed normal erythrocyte sedimentation rate.", + "Routine blood tests showed normal alkaline phosphatase.", + "Routine blood tests showed normal blood sugar.", + "Routine blood tests showed normal blood trioxypurine.", + "X-ray showed a bone mass in front of the right tibia.", + "CT showed multiple patchy bone masses with uneven bone density in front of the upper segment of the right tibia and the dorsum of the right foot.", + "The edge of the right ankle joint was osteosclerotic.", + "The joint space was adequate." + ], + "summary": "We report a patient with massive HO in front of the ankle joint for 23 years. In 1998, the patient was injured by a falling object on the right lower extremity, which gradually formed a massive heterotopic bone change in the right calf and dorsum of the foot. The patient did not develop gradual ankle function limitations until nearly 36 mo ago, and underwent resection of HO. Even after 23 years and resection of HO, the ankle joint was still able to move.", + "summary_subclaims": [ + "The patient had massive HO in front of the ankle joint for 23 years.", + "In 1998, the patient was injured by a falling object on the right lower extremity.", + "A massive heterotopic bone change gradually formed in the right calf and dorsum of the foot.", + "The patient did not develop gradual ankle function limitations until nearly 36 mo ago.", + "The patient underwent resection of HO.", + "Even after 23 years and resection of HO, the ankle joint was still able to move." + ] + }, + { + "id": "multiclinsum_test_2907_en.txt", + "fulltext": "A 12-year-old Amara male patient presented to University of Gondar comprehensive specialized hospital, Northwestern Ethiopia, with a complaint of right lateral neck swelling of 6 months duration. The swellings were painless and reported to have increased in size. He had visited a nearby health center on multiple occasions for this complaint and took unspecified antibiotics, but no improvement. There was no history of fever, cough, weight loss, night sweating, loss of appetite, pressure effects, or bowel, bladder, joints or nervous system involvement. He had no family history (first-degree relatives) of diabetes, hypertension, or any other remarkable noncommunicable disease, including cancer. His past medical history is not significant. He had no history of admission to hospital. He had no history of any form of surgical procedures. He was a grade four student in a public school at the time of presentation. On physical examination, there were six discrete firm, nontender, freely mobile right lateral cervical lymphadenopathies, the largest measuring 3 × 2 cm2 . On the basis of the above findings, a provisional clinical impression of lateral cervical lymphadenopathy, due to either lymphoma or tuberculosis, was entertained.\nLiver was not palpable below costal margin. There was no splenomegaly. Other clinical findings were within normal limits. Laboratory investigations done on the same day of his presentation, including complete blood count (CBC), erythrocyte sedimentation rate (ESR), and chest X-ray, were noncontributory. On CBC, total white blood cell (WBC) count was 5800 µL with 50% granulocytes, 45% lymphocytes, 1% eosinophils, and 4% monocytes. Platelet count was 300,000 µL. Hemoglobin was 14.5 g/dL with mean corpuscular volume (MCV) of 88 fL. ESR was 14 mm/hour. Renal function test revealed blood urea nitrogen (BUN) of 12 mg/dL, and serum creatinine level was 0.68 mg/dL. On liver function test, total bilirubin was 0.6 mg/dL, serum albumin was 4.2 g/dL, and serum aspartate transaminase (AST/SGOT) and serum alanine transaminase (ALT/SGPT) were 30 and 32 IU/L, respectively. Urinalysis was also done and it was normal. Sputum was negative for acid-fast bacilli. Serum was negative for HIV antibody. Chest X-ray and ultrasound of abdomen did not reveal any abnormality.\nDue to limited number of pathologists and long waiting list of patients, he underwent fine needle aspiration cytology (FNAC). After 2 weeks of his initial presentation, FNAC from cervical lymph node was done and smears were stained with Wright’s stain following the standard procedures. Microscopic examination showed intracellular and extracellular Leishmania donovani (LD) bodies on polymorphous background . Serum tested for anti-rK39 antibodies was strongly positive. Bone marrow aspirations done on two occasions were negative for LD bodies. On the basis of above findings, the case was diagnosed as lymphatic leishmaniasis and the patient was put on sodium stibogluconate (20 mg/kg body weight/day), and paromomycin (15 mg/kg body weight/day) injections, which were given intramuscularly for 17 days and defined as the preferred first-line regimens for primary VL in Ethiopia.\nHaving completed his medication at the University of Gondar comprehensive specialized hospital, he had a smooth course and was discharged with an appointment scheduled for follow-up after 3 months. When he came for the follow-up after 3 months, he had right lateral neck small mobile lymph nodes and was discharged with advice to return to the University of Gondar comprehensive specialized hospital if there was any new-onset increment of his right lateral neck small mobile lymph nodes.", + "fulltext_subclaims": [ + "The patient is a 12-year-old Amara male.", + "He presented with right lateral neck swelling of 6 months duration.", + "The swellings were painless.", + "The swellings were reported to have increased in size.", + "He had visited a nearby health center on multiple occasions for this complaint.", + "He took unspecified antibiotics.", + "There was no improvement.", + "There was no history of fever.", + "There was no history of cough.", + "There was no history of weight loss.", + "There was no history of night sweating.", + "There was no history of loss of appetite.", + "There was no history of pressure effects.", + "There was no history of bowel, bladder, joints, or nervous system involvement.", + "There was no family history of diabetes.", + "There was no family history of hypertension.", + "There was no family history of any other noncommunicable disease.", + "His past medical history is not significant.", + "He had no history of hospital admission.", + "He had no history of surgical procedures.", + "On physical examination, there were six discrete firm, nontender, freely mobile right lateral cervical lymphadenopathies.", + "The largest lymph node measured 3 × 2 cm2.", + "A provisional clinical impression of lateral cervical lymphadenopathy was entertained.", + "Laboratory investigations included complete blood count, ESR, and chest X-ray.", + "Total white blood cell count was 5800 µL.", + "Granulocytes were 50%.", + "Lymphocytes were 45%.", + "Eosinophils were 1%.", + "Monocytes were 4%.", + "Platelet count was 300,000 µL.", + "Hemoglobin was 14.5 g/dL.", + "Mean corpuscular volume was 88 fL.", + "ESR was 14 mm/hour.", + "Blood urea nitrogen was 12 mg/dL.", + "Serum creatinine was 0.68 mg/dL.", + "Total bilirubin was 0.6 mg/dL.", + "Serum albumin was 4.2 g/dL.", + "Serum aspartate transaminase was 30 IU/L.", + "Serum alanine transaminase was 32 IU/L.", + "Urinalysis was normal.", + "Sputum was negative for acid-fast bacilli.", + "Serum was negative for HIV antibody.", + "Chest X-ray and ultrasound of abdomen did not reveal any abnormality.", + "He underwent fine needle aspiration cytology.", + "FNAC from cervical lymph node was done after 2 weeks of initial presentation.", + "Microscopic examination showed intracellular and extracellular Leishmania donovani bodies.", + "Serum tested for anti-rK39 antibodies was strongly positive.", + "Bone marrow aspirations done on two occasions were negative for LD bodies.", + "The case was diagnosed as lymphatic leishmaniasis.", + "The patient was put on sodium stibogluconate.", + "The patient was put on paromomycin.", + "Sodium stibogluconate was given intramuscularly at 20 mg/kg body weight/day.", + "Paromomycin was given intramuscularly at 15 mg/kg body weight/day.", + "The treatment was given for 17 days.", + "The treatment was defined as the preferred first-line regimens for primary VL in Ethiopia.", + "He had a smooth course and was discharged.", + "He was scheduled for follow-up after 3 months.", + "At follow-up after 3 months, he had right lateral neck small mobile lymph nodes.", + "He was discharged with advice to return if there was any new-onset increment of his right lateral neck small mobile lymph nodes." + ], + "summary": "A 12-year-old Amara male patient presented to the University of Gondar comprehensive specialized hospital, Northwestern Ethiopia, with six discrete right lateral cervical lymphadenopathies, the largest measuring 3 × 2 cm2, with no cutaneous lesion. Fine needle aspiration cytology confirmed the diagnosis of leishmaniasis in lymph node, and he was put on sodium stibogluconate (20 mg/kg body weight/day) and paromomycin (15 mg/kg body weight/day) injections, which are given intramuscularly for 17 days. Having completed his medication at the University of Gondar comprehensive specialized hospital, he had a smooth course and was discharged with appointment scheduled for follow-up after 3 months.", + "summary_subclaims": [ + "The patient is a 12-year-old Amara male.", + "The patient presented to the University of Gondar comprehensive specialized hospital.", + "The patient had six discrete right lateral cervical lymphadenopathies.", + "The largest lymph node measured 3 × 2 cm2.", + "There was no cutaneous lesion.", + "Fine needle aspiration cytology confirmed the diagnosis of leishmaniasis in lymph node.", + "The patient was put on sodium stibogluconate at 20 mg/kg body weight/day.", + "The patient was put on paromomycin at 15 mg/kg body weight/day.", + "The medications were given intramuscularly.", + "The treatment duration was 17 days.", + "The patient completed his medication at the University of Gondar comprehensive specialized hospital.", + "The patient had a smooth course.", + "The patient was discharged.", + "The patient was scheduled for follow-up after 3 months." + ] + }, + { + "id": "multiclinsum_test_422_en.txt", + "fulltext": "A 60-year-old denture-wearing Malaysian woman was referred to the Oral Medicine Clinic, Universiti Malaya, in February 2020, with the complaint of a painless swelling on her lower right cheek for a month. She also had moderate xerostomia, with a Clinical Oral Dryness Score of five [, ]. Upon examination, the patient was partially edentulous with no obvious facial swelling or palpable lymph nodes. Slight erythema was noted at the bilateral angle of her mouth, suggestive of angular cheilitis. A non-tender, non-indurated lump measuring 0.5 × 0.5 cm resembling an irritation fibroma, most likely caused by an ill-fitting denture, was observed on her lower right buccal sulcus over the premolar region.\nAn oral swab was collected from the bilateral angle of her mouth for Gram staining and cultured for Candida yeasts on Brilliance Candida agar™ (BCA) (Oxoid, UK). An expectorated oral rinse sample collected from gargling 20 ml of saline was also obtained and centrifuged at 9600 revolutions per minute at 4 ºC for 10 min. The pellet (100 μl) was cultured for isolation of Candida yeasts. Gram-stained smear of the oral swab showed presence of scanty Gram-positive and Gram-negative bacteria and epithelial cells. Blastoconidia or hyphal filaments were not observed. Primary cultures from the oral swab and oral rinse samples grew dark blue colonies along the initial streak lines on BCA upon incubation at 37 °C after 48 h of incubation. The colonies were subcultured onto fresh BCA and Sabouraud’s dextrose agar (SDA) plates for incubation at room temperature and 37 °C. Smooth, mucoidal, and light orange or beige colonies were observed on SDA at both temperatures. Similar colonies were observed on BCA at room temperature; however, dark blue colonies were observed on BCA at 37 °C. The yeast growth was generally faster at room temperature compared to 37 ºC on both agar media. Gram stain examination of a pure culture showed round-to-oval yeast morphology. The yeast isolated was assigned as C. calyptogenae strain D1.\nThe yeast was identified to the species level through polymerase chain reaction (PCR) amplification and sequence determination of the internal transcribed spacer (ITS) gene and D1/D2 domain of the large subunit (LSU) ribosomal DNA (rDNA) of the yeast. The freeze–thaw method as described by Silva et al. was used to extract yeast DNA. Two sets of primers, ITS1 (5ʹ-TCC GTA GGT GAA CCT GCG G-3ʹ) and ITS4 (5ʹ-TCC TCC GCT TAT TGA TAT GC-3ʹ) , and primer pair NL1 (5ʹ- GCA TAT CAA TAA GCG GAG GAA AAG-3ʹ) and NL4 (5ʹ-GGT CCG TGT TTC AAG ACG G-3ʹ) were used for species identification. The PCR reaction mixture (25 μl) contained 2 μl (16 ng) of DNA extract, 1 μM of each primer, 12.5 μl of exTen 2 × PCR Master Mix (1st Base, Singapore). The PCR amplification conditions included 5 min denaturation at 95 ºC for 1 cycle, followed by 35 cycles of 95 ºC for 1 min, 52 ºC for 1 min, 72 ºC for 1 min and one final extension step of 72 ºC for 10 min. The nucleotide sequences of the amplified products were determined by a commercial sequencing provider (Apical Scientific, Malaysia), using forward and reverse PCR primers. The sequences were assembled on the Biological Sequence Alignment Editing (Bioedit) software (RRID: SCR_007361) and searched for the highest sequence similarity using the GenBank Basic Local Alignment Search Tool (BLASTn) (RRID: SCR_004870) against the National Centre for Biotechnology Information (NCBI) nucleotide database (RRID: SCR_004860). A phylogenetic tree was constructed on the Molecular Evolutionary Genetics Analysis (MEGA) software (RRID: SCR_000667) using ITS gene sequences of C. calyptogenae strains retrieved from the GenBank database. Erythrobasidium hasegawianum strain CBS 8253 (AF444522) was used as an outgroup.\nThe yeast D1/D2 domain sequence (GenBank accession no. OK147747) was 100% (558/558 nucleotides) similar to the C. calyptogenae CBS 9125 type strain, which was first isolated from a giant white clam (AB025996) . Other strains demonstrating 100% sequence similarity include C. calyptogenae strain 4107 (EU669877) , which was isolated from seawater in Taiwan, and strain CBS 11058 from a culture collection . Meanwhile, the yeast ITS sequence (GenBank accession no. OK147742) exhibited 100% (463/463 nucleotides) similarity to C. calyptogenae strain 4107 (EU669877) , and CBS 11134 (KY103129) but 99.5% (2 nucleotide difference) to C. calyptogenae CBS 9125 type strain. Figure shows the phylogenetic tree constructed based on ITS sequences of various Cystobasidium reference strains. Strain D1 was clustered with C. calyptogenae CBS 9125 type strain, and other known C. calyptogenae strains in the same branch with high bootstrap value (100%). Based on phylogenetic analysis, the identity of strain D1 was thus confirmed as C. calyptogenae.\nThe patient was given topical treatment with 2% miconazole and fusidic acid, once daily, for the management of angular cheilitis. Mouthwash (Oral-7) was provided to improve oral dryness. The patient was also scheduled for the construction of a new lower denture to increase the vertical dimension of the mouth to prevent recurrence of angular cheilitis. The clinical condition of the patient improved during a follow-up visit 2 weeks later, with mild erythema observed on the affected area. Repeat oral swab and oral rinse cultures were negative for C. calyptogenae. However, a mixed growth of yeasts (Trichosporon asahii, Candida dubliniensis, and Candida parapsilosis) was noted in the oral rinse sample. Similar treatment was thus continued for another 2 weeks and the patient was placed on an open appointment that required her to come to the clinic only if the symptoms persisted.", + "fulltext_subclaims": [ + "A 60-year-old denture-wearing Malaysian woman was referred to the Oral Medicine Clinic, Universiti Malaya, in February 2020.", + "She had a painless swelling on her lower right cheek for a month.", + "She had moderate xerostomia, with a Clinical Oral Dryness Score of five.", + "Upon examination, the patient was partially edentulous with no obvious facial swelling or palpable lymph nodes.", + "Slight erythema was noted at the bilateral angle of her mouth, suggestive of angular cheilitis.", + "A non-tender, non-indurated lump measuring 0.5 × 0.5 cm resembling an irritation fibroma was observed on her lower right buccal sulcus over the premolar region.", + "An oral swab was collected from the bilateral angle of her mouth for Gram staining and cultured for Candida yeasts on Brilliance Candida agar™.", + "An expectorated oral rinse sample collected from gargling 20 ml of saline was obtained and centrifuged at 9600 revolutions per minute at 4 ºC for 10 min.", + "Gram-stained smear of the oral swab showed presence of scanty Gram-positive and Gram-negative bacteria and epithelial cells.", + "Blastoconidia or hyphal filaments were not observed.", + "Primary cultures from the oral swab and oral rinse samples grew dark blue colonies along the initial streak lines on BCA upon incubation at 37 °C after 48 h of incubation.", + "The colonies were subcultured onto fresh BCA and Sabouraud’s dextrose agar (SDA) plates for incubation at room temperature and 37 °C.", + "Smooth, mucoidal, and light orange or beige colonies were observed on SDA at both temperatures.", + "Similar colonies were observed on BCA at room temperature; however, dark blue colonies were observed on BCA at 37 °C.", + "The yeast growth was generally faster at room temperature compared to 37 ºC on both agar media.", + "Gram stain examination of a pure culture showed round-to-oval yeast morphology.", + "The yeast isolated was assigned as C. calyptogenae strain D1.", + "The yeast was identified to the species level through polymerase chain reaction (PCR) amplification and sequence determination of the internal transcribed spacer (ITS) gene and D1/D2 domain of the large subunit (LSU) ribosomal DNA (rDNA) of the yeast.", + "The freeze–thaw method as described by Silva et al. was used to extract yeast DNA.", + "Two sets of primers, ITS1 and ITS4, and primer pair NL1 and NL4 were used for species identification.", + "The PCR reaction mixture (25 μl) contained 2 μl (16 ng) of DNA extract, 1 μM of each primer, 12.5 μl of exTen 2 × PCR Master Mix.", + "The PCR amplification conditions included 5 min denaturation at 95 ºC for 1 cycle, followed by 35 cycles of 95 ºC for 1 min, 52 ºC for 1 min, 72 ºC for 1 min and one final extension step of 72 ºC for 10 min.", + "The nucleotide sequences of the amplified products were determined by a commercial sequencing provider.", + "The sequences were assembled on the Biological Sequence Alignment Editing (Bioedit) software.", + "The sequences were searched for the highest sequence similarity using the GenBank Basic Local Alignment Search Tool (BLASTn) against the National Centre for Biotechnology Information (NCBI) nucleotide database.", + "A phylogenetic tree was constructed on the Molecular Evolutionary Genetics Analysis (MEGA) software using ITS gene sequences of C. calyptogenae strains retrieved from the GenBank database.", + "Erythrobasidium hasegawianum strain CBS 8253 was used as an outgroup.", + "The yeast D1/D2 domain sequence was 100% similar to the C. calyptogenae CBS 9125 type strain.", + "The yeast ITS sequence exhibited 100% similarity to C. calyptogenae strain 4107.", + "The yeast ITS sequence exhibited 99.5% similarity to C. calyptogenae CBS 9125 type strain.", + "Strain D1 was clustered with C. calyptogenae CBS 9125 type strain, and other known C. calyptogenae strains in the same branch with high bootstrap value (100%).", + "Based on phylogenetic analysis, the identity of strain D1 was thus confirmed as C. calyptogenae.", + "The patient was given topical treatment with 2% miconazole and fusidic acid, once daily, for the management of angular cheilitis.", + "Mouthwash (Oral-7) was provided to improve oral dryness.", + "The patient was scheduled for the construction of a new lower denture to increase the vertical dimension of the mouth to prevent recurrence of angular cheilitis.", + "The clinical condition of the patient improved during a follow-up visit 2 weeks later, with mild erythema observed on the affected area.", + "Repeat oral swab and oral rinse cultures were negative for C. calyptogenae.", + "A mixed growth of yeasts (Trichosporon asahii, Candida dubliniensis, and Candida parapsilosis) was noted in the oral rinse sample.", + "Similar treatment was thus continued for another 2 weeks.", + "The patient was placed on an open appointment that required her to come to the clinic only if the symptoms persisted." + ], + "summary": "Angular cheilitis was diagnosed in a 60-year-old denture-wearing woman who presented with an irritation fibroma on her right lower buccal sulcus over the premolar region. Primary cultures of her oral swab and oral rinse samples grew a pure culture of an uncommon yeast strain resembling Rhodotorula sp. Sequence analysis of the yeast internal transcribed spacer (ITS) gene region and D1D2 domain showed highest similarity (99.6% and 100%, respectively) to C. calyptogenae CBS 9125 type strain. Following 2 weeks of treatment with miconazole/fusidic acid and mouthwash, the oral lesion showed improvement with less erythema. C. calyptogenae was not isolated from the patient's oral samples upon repeat sampling.", + "summary_subclaims": [ + "Angular cheilitis was diagnosed in a 60-year-old denture-wearing woman.", + "The patient presented with an irritation fibroma on her right lower buccal sulcus over the premolar region.", + "Primary cultures of her oral swab and oral rinse samples grew a pure culture of an uncommon yeast strain resembling Rhodotorula sp.", + "Sequence analysis of the yeast internal transcribed spacer (ITS) gene region showed highest similarity (99.6%) to C. calyptogenae CBS 9125 type strain.", + "Sequence analysis of the yeast D1D2 domain showed highest similarity (100%) to C. calyptogenae CBS 9125 type strain.", + "Following 2 weeks of treatment with miconazole/fusidic acid and mouthwash, the oral lesion showed improvement with less erythema.", + "C. calyptogenae was not isolated from the patient's oral samples upon repeat sampling." + ] + }, + { + "id": "multiclinsum_test_2339_en.txt", + "fulltext": "In October 2011, a 70-year-old Han Chinese woman with Type 2 diabetes (T2D) was admitted to Department of Endocrinology at the Tianjin Medical University General Hospital for uncontrolled hyperglycemia. The patient had a history of T2D for 21 years and received continuous long-term insulin treatment with a dosage of about fifty units per day. On the seventh day after admission, the patient developed symptoms of nausea and vomiting accompanied by left leg radiating pain without diarrhea and fever. She did not present with headache, dizziness, disturbance of consciousness, melana or hematemesis. The medications used in the hospital are listed in Table . The patient had no recent history of using diuretic agents. Serum sodium levels decreased to 112 mmol/l and chloride levels to 81 mmol/l with an effective osmolality at 267 mOsm/kg.H2O (normal range: 280–310 mOsm/kg.H2O). Urinary sodium increased to 85 mmol/l and chloride to 86 mmol/l with an osmolality of 257 mOsm/kg.H2O indicating hypotonicity during normal dietary salt intake. She was clinically normovolemic with no signs of fluid retention. Her hepatic and renal functions were normal with a serum creatinine of 68 (normal range: 44–115) umol/L. Fractional sodium excretion was calculated as 1.56%. Thyroid and adrenal function were measured with ACTH = 59.8 pg/mL(normal range: 0–46), cortisol = 25.6 ug/dL(normal range: 5–25), 24-hour cortisol in urine = 64.4 ug(normal range: 30–110), FT3 = 3.04 pmol/L(normal range: 3.5–6.5), FT4 = 19.76 pmol/L(normal range: 11.5–23.5), TSH = 3.657 uIU/mL(normal range: 0.3–5.0) and rT3 = 1.76 nmol/l (normal range: 0.43–1.15). The magnetic resonance imaging (MRI) of her pituitary gland showed herniation of the suprasellar cistern. Based on the MRI result, our first diagnosis was hypopituitarism, which was treated with intravenous hydrocortisone at 50 mg/day. Both the serum sodium and serum chloride increased from 112 to 116 mmol/l and from 81 to 84 mmol/l, respectively, on the following day.\nAfter further inquiry, the patient informed us of a past history of Mucosal-associated lymphoid tissue lymphoma (MALT) which had not received further treatment. We also discovered that she was last hospitalized on March 2011 for uncontrolled hyperglycemia without symptoms of nausea and vomiting. Nevertheless, hyponatremia had been noticed with serum sodium of 131 mmol/L and serum chloride of 95 mmol/l. Urinary investigation showed increased levels of sodium (90 mmol/l) and chloride (83 mmol/l) without corresponding osmolality data. Her renal function was normal with a serum creatinine of 63 umol/L. This information led us to believe that SIADH caused the patient’s hyponatremia. Three days after restricting fluid intake to 1000 ml/day, the serum sodium rose to 128 mmol/L from 116 mmol/L. Ten days later, the patient’s serum sodium levels increased to 142 mmol/l, and the symptoms of nausea and vomiting disappeared.\nSince the patient had a past history of MALT, we performed a gastric endoscopy, which indicated the absence of lymphoma. Additionally, the serology result was negative for purified protein derivative (PPD), and the serum and urine protein electrophoresis were also negative for monoclonal gammopathy. Additional laboratory findings were listed in Table . A negative chest computed tomography (CT) scan excluded the possibility of SCLC as the cause of SIADH in this patient. However, we noticed that the patient had obvious pain in the left leg, abdominal distension, and skin itching on a clinical exam and further discovered that her abdomen circumference had increased significantly in the last six months. An abdominal CT scan showed that a mass measuring approximately 49 mm*70 mm*90 mm was located on front lumbar vertebra 1–4 and the surrounding abdominal aorta. A subsequent abdominal enhancement CT revealed that the mass might be lymphoma . As the pathological result was critical for her diagnosis, we conducted a left inguinal lymph node puncture showing no abnormal lymphocytes. Consequently, a whole left inguinal (2 × 1 × 0.5 cm) lymph node was resected. The pathological morphology revealed that the lymph node structure was replaced with substantial amounts of lymphoid tissue and fibrosis. Thus, the diagnosis of Castleman’s disease was established according to the pathological exam .\nAlthough hyponatremia was corrected, her hemoglobulin levels decreased from 109 g/L to 96 g/L. With her consent, we conducted a biopsy of the enlarged abdominal lymph node by using a celioscope. The pathological exam disclosed diffuse large B-cell lymphoma with an anaplastic subtype .\nAfter the diagnosis of lymphoma was established, the patient was transferred to the Department of Hematology for further treatment. For the etiology treatment of B-cell lymphoma, the chemotherapy of cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone (CHOP) with rituximab (a monoclonal antibody against the protein CD20) was administered. The patient’s serum sodium level stabilized without fluid restriction.", + "fulltext_subclaims": [ + "The patient was a 70-year-old Han Chinese woman.", + "The patient had a history of Type 2 diabetes for 21 years.", + "The patient received continuous long-term insulin treatment with a dosage of about fifty units per day.", + "On the seventh day after admission, the patient developed symptoms of nausea and vomiting.", + "The patient had left leg radiating pain.", + "The patient did not have diarrhea.", + "The patient did not have fever.", + "The patient did not present with headache.", + "The patient did not present with dizziness.", + "The patient did not present with disturbance of consciousness.", + "The patient did not present with melena.", + "The patient did not present with hematemesis.", + "Serum sodium levels decreased to 112 mmol/l.", + "Serum chloride levels decreased to 81 mmol/l.", + "Urinary sodium increased to 85 mmol/l.", + "Urinary chloride increased to 86 mmol/l.", + "The patient was clinically normovolemic.", + "The patient had no signs of fluid retention.", + "Serum creatinine was 68 umol/L.", + "Fractional sodium excretion was calculated as 1.56%.", + "ACTH was 59.8 pg/mL.", + "Cortisol was 25.6 ug/dL.", + "24-hour cortisol in urine was 64.4 ug.", + "FT3 was 3.04 pmol/L.", + "FT4 was 19.76 pmol/L.", + "TSH was 3.657 uIU/mL.", + "rT3 was 1.76 nmol/l.", + "MRI of the pituitary gland showed herniation of the suprasellar cistern.", + "The first diagnosis was hypopituitarism.", + "The patient was treated with intravenous hydrocortisone at 50 mg/day.", + "Serum sodium increased from 112 to 116 mmol/l on the following day.", + "Serum chloride increased from 81 to 84 mmol/l on the following day.", + "The patient had a past history of Mucosal-associated lymphoid tissue lymphoma.", + "The patient had not received further treatment for MALT.", + "The patient was last hospitalized on March 2011 for uncontrolled hyperglycemia.", + "Hyponatremia had been noticed with serum sodium of 131 mmol/L.", + "Urinary investigation showed increased levels of sodium (90 mmol/l).", + "Urinary investigation showed increased levels of chloride (83 mmol/l).", + "The patient’s serum sodium rose to 128 mmol/L from 116 mmol/L after three days of fluid restriction.", + "The patient’s serum sodium levels increased to 142 mmol/l ten days after admission.", + "The symptoms of nausea and vomiting disappeared.", + "A gastric endoscopy indicated the absence of lymphoma.", + "The serology result was negative for purified protein derivative.", + "The serum and urine protein electrophoresis were negative for monoclonal gammopathy.", + "A negative chest CT scan excluded the possibility of SCLC as the cause of SIADH.", + "An abdominal CT scan showed a mass measuring approximately 49 mm*70 mm*90 mm.", + "A subsequent abdominal enhancement CT revealed that the mass might be lymphoma.", + "A left inguinal lymph node puncture showed no abnormal lymphocytes.", + "A whole left inguinal lymph node was resected.", + "The diagnosis of Castleman’s disease was established.", + "The patient’s hemoglobulin levels decreased from 109 g/L to 96 g/L.", + "A biopsy of the enlarged abdominal lymph node was conducted.", + "The pathological exam disclosed diffuse large B-cell lymphoma with an anaplastic subtype.", + "The patient was transferred to the Department of Hematology.", + "The chemotherapy of cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone (CHOP) with rituximab was administered.", + "The patient’s serum sodium level stabilized without fluid restriction." + ], + "summary": "A 70-year-old Chinese woman with a history of diabetes mellitus and insulin therapy had severe hyponatremia and gastrointestinal symptoms. Through a series of examinations, common causes such as pulmonary carcinoma were excluded. An abdominal mass was detected by computed tomography. Although the peripheral lymph node biopsy showed the pathological result as Castleman's disease, the pathology of the abdominal lymph node revealed diffuse large B-cell lymphoma. After chemotherapy, the hyponatremia was treated during a period of follow-up.", + "summary_subclaims": [ + "The patient is a 70-year-old Chinese woman.", + "The patient has a history of diabetes mellitus.", + "The patient was receiving insulin therapy.", + "The patient had severe hyponatremia.", + "The patient had gastrointestinal symptoms.", + "Common causes such as pulmonary carcinoma were excluded.", + "An abdominal mass was detected by computed tomography.", + "The peripheral lymph node biopsy showed the pathological result as Castleman's disease.", + "The pathology of the abdominal lymph node revealed diffuse large B-cell lymphoma.", + "After chemotherapy, the hyponatremia was treated during a period of follow-up." + ] + }, + { + "id": "multiclinsum_test_955_en.txt", + "fulltext": "A 75-year-old man was admitted for the treatment of an asymptomatic left CIA aneurysm. The aneurysm was diagnosed during a routine abdominal ultrasound. A computed tomography angiography (CTA) revealed an isolated left CIA aneurysm and a left pelvic kidney . The maximum diameter of the CIA aneurysm was 32 mm. The congenital pelvic kidney was supplied by three small superior polar arteries that emerged from the proximal non-aneurysmal portion of the CIA and the main artery that arose from the internal iliac artery . The distance between the superior polar arteries and the beginning of the aneurysm was 28,9 mm. The special issues about this case was to preserve all of the blood supply of the pelvic kidney and exclude the aneurysm. It was accomplished by using an iliac branch device (IBD) (Gore Excluder Iliac Branch, Flagstaff, AZ) without an aortic stent graft . Preoperative serum blood urea nitrogen and creatinine levels were 22 and 1,03 mg/dl, respectively. There was no change in the postoperative period.\nAfter induction of general anesthesia, we performed the Preclose technique via bilateral femoral artery access, guided by ultrasound, with two Perclose Proglide (Abbott Vascular) for each site. After achieving access, the patient was systematically heparinized. A 16Fr Dry Seal Flex Introducer Sheath (Gore, Flagstaff, AZ) was advanced over an Extra Stiff Wire Guide in the ipsilateral site, and a 12Fr Dry Seal Flex Introducer Sheath (Gore, Flagstaff, AZ) was advanced over an Extra Stiff Wire Guide in the contralateral site. A vertebral catheter and a hydrophilic guidewire were introduced via the 16Fr Sheath, and an EN Snare (Merit Medical System, Malvern, PA) was introduced in the contralateral 12Fr Sheath, establishing the through-and-through femoral access. After, we advanced the IBD (23x12x10 mm) into position over both wires. The first step of deployment was done, releasing the iliac branch portal. The 12 Fr Sheath was advanced up and over the aortic bifurcation using a pushing and pull movement and the catheterization of the internal iliac artery was performed with a vertebral catheter and hydrophilic guidewire, with was later replaced by an Amplatz. Support Wire Guide 1 cm short tip that allowed to advance the internal iliac component (16x14x10 mm) into the internal iliac artery. The iliac branch portal was dilated using a 14 mm angioplasty balloon Zeppelin (Scitech, Aparecida de Goias, GO). The second step of the IBD was done with the release of the external iliac branch. After, kissing-balloon angioplasty was performed using a Giant Balloon Catheter (Scitech, Aparecida de Goias, GO) for the external iliac component. Completion angiography was performed demonstrating exclusion of the aneurysm, preservation off all renal arteries without endoleaks.\nA CTA was performed 1 and 6 months after the procedure and demonstrated complete exclusion of the aneurysm and preservation of all renal arteries .", + "fulltext_subclaims": [ + "A 75-year-old man was admitted for the treatment of an asymptomatic left CIA aneurysm.", + "The aneurysm was diagnosed during a routine abdominal ultrasound.", + "A computed tomography angiography (CTA) revealed an isolated left CIA aneurysm.", + "The maximum diameter of the CIA aneurysm was 32 mm.", + "The distance between the superior polar arteries and the beginning of the aneurysm was 28,9 mm.", + "The special issues about this case was to preserve all of the blood supply of the pelvic kidney and exclude the aneurysm.", + "It was accomplished by using an iliac branch device (IBD) (Gore Excluder Iliac Branch, Flagstaff, AZ) without an aortic stent graft.", + "Preoperative serum blood urea nitrogen and creatinine levels were 22 and 1,03 mg/dl, respectively.", + "There was no change in the postoperative period.", + "After induction of general anesthesia, we performed the Preclose technique via bilateral femoral artery access, guided by ultrasound, with two Perclose Proglide (Abbott Vascular) for each site.", + "A 16Fr Dry Seal Flex Introducer Sheath (Gore, Flagstaff, AZ) was advanced over an Extra Stiff Wire Guide in the ipsilateral site.", + "A 12Fr Dry Seal Flex Introducer Sheath (Gore, Flagstaff, AZ) was advanced over an Extra Stiff Wire Guide in the contralateral site.", + "A vertebral catheter and a hydrophilic guidewire were introduced via the 16Fr Sheath.", + "An EN Snare (Merit Medical System, Malvern, PA) was introduced in the contralateral 12Fr Sheath, establishing the through-and-through femoral access.", + "The IBD (23x12x10 mm) was advanced into position over both wires.", + "The first step of deployment was done, releasing the iliac branch portal.", + "The 12 Fr Sheath was advanced up and over the aortic bifurcation using a pushing and pull movement.", + "The catheterization of the internal iliac artery was performed with a vertebral catheter and hydrophilic guidewire.", + "The iliac branch portal was dilated using a 14 mm angioplasty balloon Zeppelin (Scitech, Aparecida de Goias, GO).", + "The second step of the IBD was done with the release of the external iliac branch.", + "Kissing-balloon angioplasty was performed using a Giant Balloon Catheter (Scitech, Aparecida de Goias, GO) for the external iliac component.", + "Completion angiography was performed demonstrating exclusion of the aneurysm, preservation off all renal arteries without endoleaks.", + "A CTA was performed 1 and 6 months after the procedure and demonstrated complete exclusion of the aneurysm.", + "A CTA was performed 1 and 6 months after the procedure and demonstrated preservation of all renal arteries." + ], + "summary": "We present a case of successful repair of an isolated common iliac artery aneurysm associated with a congenital pelvic kidney treated by an endovascular technique. A 75-year-old man was referred for the treatment of an asymptomatic left common iliac artery aneurysm. A computed tomography angiography revealed an isolated left common iliac artery aneurysm and a left pelvic kidney. The maximum diameter of the aneurysm was 32 mm. The congenital pelvic kidney was supplied by three small superior polar arteries that emerged from the proximal non-aneurysmal portion of the common iliac artery and the main artery that arose from the left internal iliac artery. The aneurysm exclusion was accomplished by using an iliac branch device (Gore Excluder Iliac Branch, Flagstaff, AZ). The 1 and 6 months computed tomography angiography after the procedure demonstrated complete exclusion of the aneurysm and preservation of all renal arteries.", + "summary_subclaims": [ + "The case involved a 75-year-old man.", + "The patient had an asymptomatic left common iliac artery aneurysm.", + "A computed tomography angiography revealed an isolated left common iliac artery aneurysm.", + "The maximum diameter of the aneurysm was 32 mm.", + "The patient had a left pelvic kidney.", + "The pelvic kidney was supplied by three small superior polar arteries.", + "The superior polar arteries emerged from the proximal non-aneurysmal portion of the common iliac artery.", + "The main artery of the pelvic kidney arose from the left internal iliac artery.", + "The aneurysm exclusion was accomplished by using an iliac branch device.", + "The 1 and 6 months computed tomography angiography after the procedure demonstrated complete exclusion of the aneurysm.", + "The 1 and 6 months computed tomography angiography after the procedure demonstrated preservation of all renal arteries." + ] + }, + { + "id": "multiclinsum_test_1355_en.txt", + "fulltext": "A 26-year-old female patient visited to the Department of Oral and Maxillofacial Surgery in April 2017, with the complaint of feeling something hard in her left cheek for a few years. She had unremarkable medical history aside from a history of trauma in the left masseteric area when she was 4 years old. On physical examinations, surface texture and color of the skin and mucosa were in normal range without swelling or tenderness. When palpated, well-defined, oval-shaped, and movable nodules in her left cheek, less than 1 cm × 1 cm in size, were identified. Panorama and CT examinations were performed, and multiple radiopaque masses were observed inside the left masseter muscle . The function of facial nerve and salivary flow of Stensen’s duct were normal. No trismus and cervical lymphadenopathy were noted. Blood test results were also normal. Serum calcium level was 9.4 g/dL and serum phosphorus level was 3.9 g/dL which were within normal ranges. From the clinical and radiographic evaluation whilst considering a history of trauma, the calcified mass was diagnosed as dystrophic calcification, which is known to occur in soft tissues, commonly in those with a history of trauma and the absence of systemic mineral imbalance.\nSurgery was planned to remove the dystrophic calcification of the left masseter muscle. After intraoral incision in the left buccal mucosa, cautious dissection of masseter muscle was done. Muscle fibers of masseter were longitudinally separated to expose the calcified masses. They were firmly attached to the masseter muscle fibers and were bluntly separated from the muscle tissue. The three calcified masses, with the largest, having a size of 0.6 × 0.5 × 0.4 cm, presenting a round-oval shape and whitish-yellow in color, were removed with the attached muscle fibers .After the calcified masses were excised completely, hemostasis was achieved and wound was sutured in layers. Postoperative recovery was uneventful with no damage to nearby structures such as nerves or Stensen’s duct. Postoperative CT imaging was taken, and complete removal of the calcified masses was confirmed . Histopathological examination revealed microscopically ovoid hyalinized material with calcification in their center but could not be found fibrous tissue or vascular structure around the materials .\nThere is a variety of conditions that may cause abnormal calcification in various tissues. It may have some connection with abnormal calcium phosphate metabolism as seen in metastatic calcifications . However, dystrophic calcification is deposition of calcium salt in degenerated tissues related to normal calcium and phosphorous metabolism . It is known that dystrophic calcification can occur in any soft tissue with the absence of a systemic mineral imbalance, easily found in the site of the heart muscle and skeletal muscle. It rarely appears in the gingiva, tongue, lymph nodes, and facial muscles and usually occurs in injured tissues [, ]. Based on the literature, our case is the fifth case of dystrophic calcification in a masseteric area to be reported .\nThe pathogenesis of dystrophic calcification is known to involve intracellular or extracellular initiation and propagation. Intracellular calcification is initiated with dead or dying cells that are not able to regulate intracellular calcium. After initiation, propagation of calcium phosphate crystalline formation occurs, which is affected by the concentration of Ca2+and PO4− in the extracellular space . Dystrophic calcification occurs when calcium is accumulated in the area of trauma or necrosis which may be caused by blunt trauma, inflammation, injections, and the presence of parasites .\nIn many cases, it appears early in childhood but it often tends to be diagnosed late since it shows no signs or symptoms. Therefore, it is found after lesion is enlarged enough to be palpated. In our case, we suppose that dystrophic calcification was caused by a trauma experienced at a young age. Because there had been no symptoms such as swelling or pain, it was discovered after a long period of time.\nDifferent types of calcifications, including phleboliths, sialoliths, myositis ossificans, metastatic calcification, calcifications within lymph nodes, and calcified cutaneous aces, may occur in the cheek area, and they need to be distinguished from dystrophic calcification. Phleboliths are pathological, calcified thrombi that are associated with hemangiomas and developmental vascular malformations of the head and neck region . Radiographically, they appear as round or oval radiopaque nodules, which may show a radiopaque center with surrounding onion ring-like concentric calcific rings . In this case, there was no evidence of hemangioma or vascular malformation clinically and radiographically. Also, the calcified mass had no radiopaque center and concentric rings.\nOn the other hand, sialoliths are one of the most common diseases that appear in the salivary glands. Sialoliths of the parotid gland or duct need to be distinguished from calcification of the cheek, because the parotid gland is located behind the masseter muscle, with the Stensen’s duct, passing through it before opening into the oral cavity. Sialoliths may be composed of one or more stones and may cause pain or swelling when the salivary gland is stimulated by eating . In our case, we ruled out a diagnosis of such because the calcified masses were located inside the masseter muscle, away from the Stensen’s duct or parotid gland based on the CT images. In addition, salivary flow of the duct was found to be normal.\nAnother differential diagnosis is myositis ossificans which results from trauma or heavy muscular strain associated with the bone or cartilage, producing reactive lesions. Clinically, it can be palpated beneath the skin or mucosa, as a minimally movable firm mass . When the lesion is located within a muscle of mastication, it usually causes trismus because of limitation of the muscle . On a radiograph, the linear streaks running in the same direction as the normal muscle fibers are regarded as a typical character for myositis ossificans . In our case, the patient had no trismus and the radiographic finding was different from myositis ossificans .\nIn addition, calcifications within lymph nodes commonly involve cervical lymph nodes with metastatic deposits from malignancies such as squamous cell carcinoma and Hodgkin’s lymphoma. On a radiograph, they most often are irregular with a cauliflower appearance . Metastatic calcifications occur due to increased calcium levels in the blood. Chronic renal failure, milk-alkali syndrome, extensive bone malignancy, and hypervitaminosis D are some of the conditions known to cause metastatic calcifications . In our case, there was no evidence of malignancy causing metastasis or systemic mineral imbalance.\nDue to this wide variety of diagnostic possibilities including phleboliths, sialoliths, myositis ossificans, calcification within lymph nodes, and the potential for malignancy, it is important to establish a proper diagnosis . In fact, physiologic and pathologic soft tissue calcification of the head and neck is rare, and plain radiography is rarely helpful in diagnosing . Therefore, thorough clinical examination and history taking is required together with blood testing and radiographic examinations such as CT, MRI, and ultrasound. In addition, fine needle aspiration for checking the contents of the lesions if deemed indicated can also help in confirming the diagnosis. The final diagnosis should be obtained after acquiring relevant information, and only then, the appropriate treatment can take place . There is no established protocol for its treatment. Some clinicians have recommended observation. However, various factors such as the size and location of the lesion, and patient discomfort should be put into consideration. In such cases and if deemed necessary, meticulous surgical excision and periodic follow up are recommended [, ].", + "fulltext_subclaims": [ + "A 26-year-old female patient visited the Department of Oral and Maxillofacial Surgery in April 2017.", + "She had a history of trauma in the left masseteric area when she was 4 years old.", + "On physical examination, surface texture and color of the skin and mucosa were in normal range.", + "Well-defined, oval-shaped, and movable nodules in her left cheek, less than 1 cm × 1 cm in size, were identified.", + "Multiple radiopaque masses were observed inside the left masseter muscle.", + "The function of facial nerve and salivary flow of Stensen’s duct were normal.", + "No trismus and cervical lymphadenopathy were noted.", + "Serum calcium level was 9.4 g/dL.", + "Serum phosphorus level was 3.9 g/dL.", + "The calcified mass was diagnosed as dystrophic calcification.", + "Surgery was planned to remove the dystrophic calcification of the left masseter muscle.", + "After intraoral incision in the left buccal mucosa, cautious dissection of masseter muscle was done.", + "The three calcified masses, with the largest having a size of 0.6 × 0.5 × 0.4 cm, were removed.", + "Postoperative CT imaging was taken, and complete removal of the calcified masses was confirmed.", + "Histopathological examination revealed microscopically ovoid hyalinized material with calcification in their center.", + "Dystrophic calcification is deposition of calcium salt in degenerated tissues related to normal calcium and phosphorous metabolism.", + "It is known that dystrophic calcification can occur in any soft tissue with the absence of a systemic mineral imbalance.", + "Our case is the fifth case of dystrophic calcification in a masseteric area to be reported.", + "Dystrophic calcification occurs when calcium is accumulated in the area of trauma or necrosis.", + "In our case, we suppose that dystrophic calcification was caused by a trauma experienced at a young age.", + "Different types of calcifications, including phleboliths, sialoliths, myositis ossificans, metastatic calcification, calcifications within lymph nodes, and calcified cutaneous aces, may occur in the cheek area.", + "Phleboliths are pathological, calcified thrombi that are associated with hemangiomas and developmental vascular malformations of the head and neck region.", + "In this case, there was no evidence of hemangioma or vascular malformation clinically and radiographically.", + "Sialoliths of the parotid gland or duct need to be distinguished from calcification of the cheek.", + "In our case, the calcified masses were located inside the masseter muscle, away from the Stensen’s duct or parotid gland.", + "Myositis ossificans results from trauma or heavy muscular strain associated with the bone or cartilage.", + "In our case, the patient had no trismus.", + "Calcifications within lymph nodes commonly involve cervical lymph nodes with metastatic deposits from malignancies.", + "Metastatic calcifications occur due to increased calcium levels in the blood.", + "In our case, there was no evidence of malignancy causing metastasis or systemic mineral imbalance.", + "Due to this wide variety of diagnostic possibilities, it is important to establish a proper diagnosis.", + "Plain radiography is rarely helpful in diagnosing physiologic and pathologic soft tissue calcification of the head and neck.", + "Thorough clinical examination and history taking is required together with blood testing and radiographic examinations.", + "The final diagnosis should be obtained after acquiring relevant information.", + "There is no established protocol for its treatment.", + "Various factors such as the size and location of the lesion, and patient discomfort should be put into consideration.", + "Meticulous surgical excision and periodic follow up are recommended." + ], + "summary": "We present a rare case of multiple calcified masses in the left masseter muscle of a 26-year-old female with a history of trauma in the area. In computed tomography, multiple radiopaque masses were observed inside the left masseter muscle and blood test results were normal. The calcified masses were diagnosed as dystrophic calcification and removed by surgery without any complications.", + "summary_subclaims": [ + "The patient is a 26-year-old female.", + "The patient has a history of trauma in the left masseter muscle area.", + "Computed tomography showed multiple radiopaque masses in the left masseter muscle.", + "Blood test results were normal.", + "The calcified masses were diagnosed as dystrophic calcification.", + "The calcified masses were removed by surgery.", + "The surgery was performed without any complications." + ] + }, + { + "id": "multiclinsum_test_3179_en.txt", + "fulltext": "An 18-year-old patient came to our clinical center for correction of local chest deformity. This patient’s chest deformity is congenital. The patient did not receive any treatment. When examining the chest, there is a complete absence of the pectoralis major muscle on the right, local retraction at the level of the 3rd and 4th intercostal spaces, incomplete development of the right nipple, and thinning of the subcutaneous fat layer of the skin.\n\nThe patient is asthenic, height - 184 cm, weight - 59 kg. BMI - 17.4. After hospitalization, the patient underwent a computed tomography scan of the chest, which revealed local depression of the chest at the level of the third and fourth ribs and deformation of the cartilaginous parts of the ribs. After preoperative preparation, the patient underwent thoracoplasty with the installation of a wire-frame structure.\n\nThe operation took place under intubation anesthesia. After processing the surgical field, an arcuate incision was made along the anterior wall of the chest from the level of the second rib on the right to the fifth intercostal space on the right. The skin is dissected, subcutaneous fat, periosteum and soft tissues are mobilized to the outer boundaries of the deformity. A defect in the third and fourth ribs on the right is visually noted. After skeletonizing the II to V rib on both sides to the outer boundaries of the deformation, the ends of the III and IV ribs were skinned. An autograft was taken from the cartilaginous part of the 5th rib. Then a frame structure is formed using Kirschner wires.\n\nAdditional costotomies of the third and fourth ribs on the right were also performed. The wound is washed and sutured tightly in layers, leaving a drainage tube. The operation time was 80 minute, intraoperative blood loss was 2000 mL. The next day after the operation, the patient was activated and rehabilitation measures were started (breathing exercises, inhalations). The drainage tube was removed on the second day after surgery. The patient was discharged 4 days after surgery. The sutures were removed 14 days after the operation. A follow-up examination of the patient was carried out 6 months after the operation. Clinical and tomographic results are satisfactory. Removal of metal structures is planned no earlier than 2 years after the operation. The purpose of our operational manual is to restore the frame structure of the cage. The second stage of surgical treatment is the replacement of the pectoralis major muscle defect with a silicone prosthesis. However, this operation is performed by aesthetic surgeons.", + "fulltext_subclaims": [ + "The patient is 18 years old.", + "The patient came to the clinical center for correction of local chest deformity.", + "The chest deformity is congenital.", + "The patient did not receive any treatment.", + "There is a complete absence of the pectoralis major muscle on the right.", + "There is local retraction at the level of the 3rd and 4th intercostal spaces.", + "There is incomplete development of the right nipple.", + "There is thinning of the subcutaneous fat layer of the skin.", + "The patient is asthenic.", + "The patient's height is 184 cm.", + "The patient's weight is 59 kg.", + "The patient's BMI is 17.4.", + "The patient underwent a computed tomography scan of the chest.", + "The CT scan revealed local depression of the chest at the level of the third and fourth ribs.", + "The CT scan revealed deformation of the cartilaginous parts of the ribs.", + "The patient underwent thoracoplasty with the installation of a wire-frame structure.", + "The operation took place under intubation anesthesia.", + "An arcuate incision was made along the anterior wall of the chest from the level of the second rib on the right to the fifth intercostal space on the right.", + "A defect in the third and fourth ribs on the right was visually noted.", + "An autograft was taken from the cartilaginous part of the 5th rib.", + "A frame structure was formed using Kirschner wires.", + "Additional costotomies of the third and fourth ribs on the right were performed.", + "The wound was washed and sutured tightly in layers, leaving a drainage tube.", + "The operation time was 80 minutes.", + "Intraoperative blood loss was 2000 mL.", + "The drainage tube was removed on the second day after surgery.", + "The patient was discharged 4 days after surgery.", + "The sutures were removed 14 days after the operation.", + "A follow-up examination of the patient was carried out 6 months after the operation.", + "Clinical and tomographic results are satisfactory.", + "Removal of metal structures is planned no earlier than 2 years after the operation.", + "The purpose of the operational manual is to restore the frame structure of the cage.", + "The second stage of surgical treatment is the replacement of the pectoralis major muscle defect with a silicone prosthesis.", + "The replacement of the pectoralis major muscle defect with a silicone prosthesis is performed by aesthetic surgeons." + ], + "summary": "We observed a patient, an 18-year-old man. The parents noticed the deformation of the chest from birth. The patient did not receive any treatment until adulthood. The patient contacted our clinical research center to correct chest deformity. After clinical and diagnostic procedures, the patient underwent surgical operation: open thoracoplasty with installation of a wire-frame construction. The early postoperative period was uneventful. Early postoperative outcome was assessed 6 months after surgery.", + "summary_subclaims": [ + "The patient is an 18-year-old man.", + "The parents noticed the deformation of the chest from birth.", + "The patient did not receive any treatment until adulthood.", + "The patient contacted our clinical research center to correct chest deformity.", + "The patient underwent surgical operation: open thoracoplasty with installation of a wire-frame construction.", + "The early postoperative period was uneventful.", + "Early postoperative outcome was assessed 6 months after surgery." + ] + }, + { + "id": "multiclinsum_test_1496_en.txt", + "fulltext": "A 32-year-old woman was admitted to the ward with a two-month history of headaches, occasionally accompanied by nausea, vomiting, and vertigo. She had a chronic daily headache, starting in the morning and becoming worse in the upright position. The headaches manifested as a dull ache with moderate to severe intensity, which was constant during the day in the frontal and occipital regions bilaterally. Her headache got better when lying down. She also had a negative history of lumbar puncture, trauma, or manipulation. There was no fever, chills, dizziness, unsteady gait, blurred vision, diplopia, or photophobia. In her past medical history, previous headaches, Ehlers-Danlos, Marfan syndrome, polycystic kidney disease, and spontaneous retinal detachment were not detected; all these conditions are related to intra-cranial hypotension. In drug history, the use of oral contraceptive pills was positive, but she did not use any other drugs. On physical examination, her vital signs were normal, with blood pressure: 12080, pulse rate: 88/minutes, respiratory rate: 16/minutes, temperature: 37.2ºC orally. General physical examination indicated that the head, neck, abdomen, extremities, and skin were normal. In addition, in neurological examination, the patient was awake, obeyed requests, and was oriented to time, place, and person. Her speech was fluent, and all cranial nerves were intact. An ophthalmologic exam showed normal eye movement and reactive pupils, and normal fundoscopic exam was detected. In the motor system, there was no atrophy, and the muscle power was 5/5. The plantar reflex was bilaterally downward and deep tendon reflexes were all 2/2. Sensory and cerebellar tests were normal, and meningeal signs were absent. She had no family history of these diseases, nor any past history of any other diseases. She was a teacher and did not have any psychiatric disorders. The patient had normal complete blood count (CBC). Brain computed tomography (CT) and magnetic resonance venography (MRV) were normal. Brain MRI, with and without gadolinium, was performed; the MRI without gadolinium was completely normal, but in the MRI with gadolinium, meningeal enhancement was clearly seen ( and ).\nA lumbar puncture was conducted, revealing an opening pressure of 2 - 3 cm H2O with no leukocytes or erythrocytes, and with normal protein and glucose levels and regular lactate dehydrogenase (LDH) . The lumbar puncture clearly worsened her positional headache. Her CT myelography from the cerebrum end to the spine revealed a normal condition, without any leakage of CSF or abnormality. Therefore, we tried to increase the intracranial pressure (ICP) of the patient with hydration, using dextrose water serum and a high caffeine diet, including drinking tea, and reducing daily activity. After two days, a significant improvement was seen in her headache.", + "fulltext_subclaims": [ + "The patient is a 32-year-old woman.", + "She had a two-month history of headaches.", + "The headaches were occasionally accompanied by nausea.", + "The headaches were occasionally accompanied by vomiting.", + "The headaches were occasionally accompanied by vertigo.", + "She had a chronic daily headache.", + "The headaches started in the morning.", + "The headaches became worse in the upright position.", + "The headaches manifested as a dull ache.", + "The headaches had moderate to severe intensity.", + "The headaches were constant during the day.", + "The headaches were in the frontal and occipital regions bilaterally.", + "The headaches got better when lying down.", + "She had a negative history of lumbar puncture.", + "She had a negative history of trauma.", + "She had a negative history of manipulation.", + "There was no fever.", + "There was no chills.", + "There was no dizziness.", + "There was no unsteady gait.", + "There was no blurred vision.", + "There was no diplopia.", + "There was no photophobia.", + "In her past medical history, previous headaches were not detected.", + "In her past medical history, Ehlers-Danlos was not detected.", + "In her past medical history, Marfan syndrome was not detected.", + "In her past medical history, polycystic kidney disease was not detected.", + "In her past medical history, spontaneous retinal detachment was not detected.", + "In drug history, the use of oral contraceptive pills was positive.", + "She did not use any other drugs.", + "Her vital signs were normal.", + "Her blood pressure was 12080.", + "Her pulse rate was 88/minutes.", + "Her respiratory rate was 16/minutes.", + "Her temperature was 37.2ºC orally.", + "General physical examination indicated that the head was normal.", + "General physical examination indicated that the neck was normal.", + "General physical examination indicated that the abdomen was normal.", + "General physical examination indicated that the extremities were normal.", + "General physical examination indicated that the skin was normal.", + "In neurological examination, the patient was awake.", + "In neurological examination, the patient obeyed requests.", + "In neurological examination, the patient was oriented to time, place, and person.", + "Her speech was fluent.", + "All cranial nerves were intact.", + "An ophthalmologic exam showed normal eye movement.", + "An ophthalmologic exam showed reactive pupils.", + "A normal fundoscopic exam was detected.", + "In the motor system, there was no atrophy.", + "The muscle power was 5/5.", + "The plantar reflex was bilaterally downward.", + "Deep tendon reflexes were all 2/2.", + "Sensory and cerebellar tests were normal.", + "Meningeal signs were absent.", + "She had no family history of these diseases.", + "She had no past history of any other diseases.", + "She was a teacher.", + "She did not have any psychiatric disorders.", + "The patient had normal complete blood count (CBC).", + "Brain computed tomography (CT) was normal.", + "Magnetic resonance venography (MRV) was normal.", + "Brain MRI, with and without gadolinium, was performed.", + "The MRI without gadolinium was completely normal.", + "In the MRI with gadolinium, meningeal enhancement was clearly seen.", + "A lumbar puncture was conducted.", + "The opening pressure was 2 - 3 cm H2O.", + "There were no leukocytes in the cerebrospinal fluid.", + "There were no erythrocytes in the cerebrospinal fluid.", + "The protein level was normal.", + "The glucose level was normal.", + "The lactate dehydrogenase (LDH) level was regular.", + "The lumbar puncture clearly worsened her positional headache.", + "Her CT myelography from the cerebrum end to the spine revealed a normal condition.", + "There was no leakage of CSF.", + "There was no abnormality in the CT myelography.", + "We tried to increase the intracranial pressure (ICP) of the patient with hydration.", + "We used dextrose water serum.", + "We used a high caffeine diet, including drinking tea.", + "We reduced daily activity.", + "After two days, a significant improvement was seen in her headache." + ], + "summary": "Here, we describe a 32-year-old woman with a two-month history of headaches and occasional nausea and vomiting (N/V). MRI without gadolinium was normal, but meningeal enhancement was seen in MRI with gadolinium. The lumbar puncture revealed a low opening pressure. Computed tomography myelography (CT myelography) showed no leakage; Therefore, idiopathic intracranial hypotension was diagnosed. Treatment was started using tea, and the patient's headache got significantly better in about a day.", + "summary_subclaims": [ + "The patient is a 32-year-old woman.", + "The patient had a two-month history of headaches.", + "The patient had occasional nausea and vomiting.", + "MRI without gadolinium was normal.", + "Meningeal enhancement was seen in MRI with gadolinium.", + "The lumbar puncture revealed a low opening pressure.", + "Computed tomography myelography showed no leakage.", + "Idiopathic intracranial hypotension was diagnosed.", + "Treatment was started using tea.", + "The patient's headache got significantly better in about a day." + ] + }, + { + "id": "multiclinsum_test_2371_en.txt", + "fulltext": "A 54-year-old Caucasian man with a 14-year history of Parkinson's disease (PD) was scheduled for DBS of the sub-thalamic nucleus (STN) bilaterally. His anti-parkinsonian medication consisted of 600 mg/day levodopa, 125 mg/day carbidopa, 1200 mg/day entacapone, and 0.54 mg/day pramipexole. This regimen was discontinued 18 hours prior to the DBS procedure, according to our standard protocol, to avoid medication-induced dyskinesias during surgery and to allow for the patient to be in an off-state, thus maximizing the clinical information gained by intra-operative stimulation . The procedure itself was uneventful, with implantation of the DBS electrodes in the STN bilaterally (Medtronic 3389 electrodes; Medtronic, Minneapolis, MN, USA). Three hours post-operatively the patient developed tremor, muscle rigidity, and high fever resistant to common anti-pyretic drugs (paracetamol 1 g). The tremor and rigidity were attributed to PD and 200 mg levodopa three times daily was administered through a nasogastric tube. Systemic and central nervous system infection were also considered in the differential diagnosis; however, cerebrospinal fluid analysis, a chest X-ray, and blood and urine cultures were all within normal limits. A subsequent brain magnetic resonance imaging scan depicted no intracranial pathology and confirmed optimal lead placement. Twelve hours postoperatively the patient's PD features worsened: He developed severe axial and appendicular rigidity, coarse resting tremor, and prolonged spasms of the extremities.\nHis temperature had risen to 40°C, and his blood pressure had increased to 165/94 mmHg. A new laboratory investigation showed leukocytosis (leukocyte count, 19.4 × 109/L with a shift to the left (neutrophil count, 167 × 109/l). His serum levels of creatine kinase (CK) were markedly elevated to 1500 U/l with a normal CK-MB fraction, and his cardiac troponin levels were normal, indicating that the CK elevation was not of cardiac origin. At that point, the diagnosis of NMS was established on the basis of the clinical examination and the laboratory findings. Malignant hyperthermia was excluded after a negative caffeine-halothane contracture test . The patient was intubated and transferred to the intensive care unit (ICU). Treatment by intravenous administration of 3 mg/kg/day dantrolene, 600 mg/day levodopa, and 60 mg apomorphine was initiated. After copious ICU treatment, the patient was extubated on the ninth post-operative day. Fifteen days post-operatively he still appeared lethargic and confused. The DBS device was consequently activated on the 20th post-operative day, as it was considered that it could accelerate the patient's recovery. Indeed, after DBS activation, the patient showed a good recovery pace and was discharged from the hospital on the 32nd post-operative day. At his six-month follow-up examination, he demonstrated an overall improvement of 15% in the Unified Parkinson Disease Rating Scale.", + "fulltext_subclaims": [ + "The patient was a 54-year-old Caucasian man.", + "The patient had a 14-year history of Parkinson's disease.", + "The patient was scheduled for DBS of the sub-thalamic nucleus bilaterally.", + "His anti-parkinsonian medication included 600 mg/day levodopa.", + "His anti-parkinsonian medication included 125 mg/day carbidopa.", + "His anti-parkinsonian medication included 1200 mg/day entacapone.", + "His anti-parkinsonian medication included 0.54 mg/day pramipexole.", + "The anti-parkinsonian medication was discontinued 18 hours prior to the DBS procedure.", + "The DBS procedure was uneventful.", + "The DBS electrodes were implanted in the STN bilaterally.", + "Three hours post-operatively, the patient developed tremor.", + "Three hours post-operatively, the patient developed muscle rigidity.", + "Three hours post-operatively, the patient developed high fever resistant to common anti-pyretic drugs.", + "The tremor and rigidity were attributed to PD.", + "200 mg levodopa three times daily was administered through a nasogastric tube.", + "Systemic and central nervous system infection were considered in the differential diagnosis.", + "Cerebrospinal fluid analysis was within normal limits.", + "A chest X-ray was within normal limits.", + "Blood and urine cultures were within normal limits.", + "A brain magnetic resonance imaging scan depicted no intracranial pathology.", + "A brain magnetic resonance imaging scan confirmed optimal lead placement.", + "Twelve hours postoperatively, the patient's PD features worsened.", + "The patient developed severe axial and appendicular rigidity.", + "The patient developed coarse resting tremor.", + "The patient developed prolonged spasms of the extremities.", + "The patient's temperature had risen to 40°C.", + "The patient's blood pressure had increased to 165/94 mmHg.", + "The laboratory investigation showed leukocytosis.", + "The leukocyte count was 19.4 × 109/L.", + "There was a shift to the left.", + "The neutrophil count was 167 × 109/l.", + "The serum levels of creatine kinase were markedly elevated to 1500 U/l.", + "The CK-MB fraction was normal.", + "The cardiac troponin levels were normal.", + "The diagnosis of NMS was established on the basis of the clinical examination and the laboratory findings.", + "Malignant hyperthermia was excluded after a negative caffeine-halothane contracture test.", + "The patient was intubated.", + "The patient was transferred to the intensive care unit.", + "Treatment by intravenous administration of 3 mg/kg/day dantrolene was initiated.", + "Treatment by intravenous administration of 600 mg/day levodopa was initiated.", + "Treatment by intravenous administration of 60 mg apomorphine was initiated.", + "The patient was extubated on the ninth post-operative day.", + "Fifteen days post-operatively, the patient still appeared lethargic and confused.", + "The DBS device was activated on the 20th post-operative day.", + "The DBS device was activated as it was considered that it could accelerate the patient's recovery.", + "After DBS activation, the patient showed a good recovery pace.", + "The patient was discharged from the hospital on the 32nd post-operative day.", + "At his six-month follow-up examination, he demonstrated an overall improvement of 15% in the Unified Parkinson Disease Rating Scale." + ], + "summary": "We present the first case of neuroleptic malignant syndrome associated with discontinuation of anti-parkinsonian medication prior to deep brain stimulation surgery in a 54-year-old Caucasian man.", + "summary_subclaims": [ + "The patient is a 54-year-old Caucasian man.", + "The case involves neuroleptic malignant syndrome.", + "The syndrome was associated with discontinuation of anti-parkinsonian medication.", + "The discontinuation occurred prior to deep brain stimulation surgery." + ] + }, + { + "id": "multiclinsum_test_2042_en.txt", + "fulltext": "A 62-year-old man with metastatic stage IV squamous cell cancer (SCC) and no prior history of autoimmune disease was treated with nivolumab every 2 weeks (3 mg/kg) from July 2016 to April 2017, resulting in complete clinical remission of his SCC. Nivolumab was ceased in April 2017, after he developed musculoskeletal irAEs with disabling polyarthritis involving shoulders, elbows, proximal interphalangeal joints and right knee, classified as a grade 3 irAE. C reactive protein (CRP) was markedly elevated at 210 mg/L. Rheumatoid factor (RF), anticyclic-citrullinated peptide antibody (ACPA) and HLA-B27 were negative, and radiographs demonstrated no erosive changes. Despite prednisolone (20–25 mg daily), intra-articular corticosteroid and sequential hydroxychloroquine (200 mg daily) and methotrexate (20 mg weekly; ), his synovitis remained active.\nGiven the lack of definitive therapeutic guidelines for rheumatic irAEs, the emergence of synovial biopsy-guided therapeutic approaches in RA and following our experience with arthroscopic ST biopsies, the patient underwent arthroscopic ST biopsy of his right knee in November 2017 (200 days following cessation of nivolumab).\nAt arthroscopy, nivolumab-induced synovitis was more severe macroscopically than the synovitis in comparator treatment-naïve early RA ST, with florid synovial hyperplasia and hypervascularization throughout (, and see ). Several ST biopsies were undertaken from areas of synovitis within the knee. Matched peripheral blood mononuclear cell (PBMC) and SF samples were collected. ST, SF and PBMC samples from this patient were compared with samples from three treatment-naïve patients with RF and/or ACPA-positive early RA (defined as within 12 months of onset of symptoms and fulfilling the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria), from whom samples were collected at the time of diagnosis. Additional PBMC and SF samples were collected from the irAE patient at the conclusion of 6 months infliximab therapy. All patients gave written informed consent.\nST samples were analyzed using histology, and flow cytometry following disaggregation. Histology was performed on serial 5m sections from formalin-fixed paraffin-embedded ST blocks. Sections were stained with H&E or labeled with the following primary antibodies for immunohistochemistry (IHC): CD45RO (Dako; UCHL1), CD55 (BioRad; C67), CD68 (Dako; KP1), TNFα (LifeSpan; C7952), IL-6 (Santa Cruz; 130326), and via a National Association of Testing Authorities approved protocol with PD-1 (CellMarque; MRQ22), PDL-1 (Ventana; SP263). Antibody-stained sections were incubated with horseradish peroxidase linked secondary antibody, followed by colorimetric visualization with either 3-amino-9-ethylcarbazole substrate-chromogen (for CD45RO, CD55, CD68, TNFα and IL-6) or 3,3′-Diaminobenzidine (for PD-1 and PDL-1). Nuclear counterstaining was performed with Mayer’s haematoxylin. Negative controls included the use of IgG isotype controls or omission of the primary antibody. Whole slide scans were captured on an Olympus VSI120 bright-field microscope at x20 magnification and sequential regions of interest compared for staining intensity. Semiquantative assessment of staining intensity was perfomed by two independent assessors using previously described techniques.\nFor flow cytometry, fresh ST was dissociated using Milytenyi Tumour Dissociation Kit (Milytenyi; 130-095-929) and the gentleMACS dissociator as per manufacturer’s recommendations. Matched SF and whole blood was collected for each patient at arthroscopy and for irAE only, after 6 months of infliximab treatment. PBMCs were purified using Lymphoprep reagent. Cells were washed and counted prior to staining for flow cytometry with Zombie UV (BioLegend) in serum free PBS, followed by washing and staining with CD45RO-UV395 (BD; UCHL1), PD1-BV421 (BD; EH12.1), CD3-PerCP/Cy5.5 (BD; SK7), CD8-Alexa647 (BD; RPA-T8), CD4-Alexa700 (BD; SK3), CD20-APC/H7 (BD; L27) in 2% Fetal calf serum. Cells were resuspended in 2% fetal calf serum ready for FACS acquisition on a BD FACSAria Fusion flow cytometer. Analysis of cytometry data was performed using FlowJo 10.4\nAnalysis of the IHC inflammatory cell infiltrate pathotype revealed lymphoid (follicular) pattern of the patient with irAE and a similar pattern in one of the RA controls; of the two other RA controls, one had diffuse and the other low (or pauci) immune infiltration. IHC of ST from the patient with irAE revealed infiltrating memory T-cells (CD45RO+) and extensive CD68 expressing macrophages (lining and sublining) , and there were no detectable B cells; in comparison, two (of the 3) RA ST revealed presence of B cells within the lymphoid aggregates and slightly less extensive CD68 expressing lining/sublining macrophages. The irAE ST displayed abundant TNFα, compared with lower levels of IL-6 labeling . This differential cytokine expression was similar to that previously observed in a proportion of patients with RA. Finally, we detected abundant levels of PDL-1 labeling in both RA and irAE ST but there was no detectable PD-1 in ST from the patient with irAE . In summary, the synovial cellular infiltrate in ST was similar to the RA ST and was indicative of TNFα dominant RA-like disease. Critically, the presence of cellular intense and dominant staining of the proinflammatory cytokine TNFα in irAE ST influenced our decision to prescribe Infliximab (an TNF antagonist) instead of an alternative bDMARD such as Tocilizumab (an IL-6R antagonist) for this irAE.\nWe then performed multiparameter flow cytometry to further characterize infiltrating T-cells in ST, SF and PBMCs in response to nivolumab-induced irAE, and, to identify changes in peripheral and SF T-cells after infliximab treatment.\nCD4 +T cells were gated and CD45RO and PD-1 expressing cells were identified . Abundant memory T-cell infiltration was observed in both ST and SF compartments for RA and irAE samples, with samples from PBMCs exhibiting lower memory T-cell frequency. Importantly, we detected a reduction in PD-1 labeling on T-cells from irAE samples compared with early RA controls. In particular, prior to commencing infliximab, there was approximately a 20-fold reduction of PD-1 +memory T cells in the SF compartment and 4-fold reduction in the ST compartment when compared with RA . Furthermore, while early RA comparators exhibited fewer peripheral PD-1 +memory T-cells in PBMCs compared with RA ST and SF compartments, we observed complete ablation of PD-1 labeling in irAE PBMC memory T-cells .\nCommencement of infliximab (5 mg/kg) led to a dramatic clinical response , coupled with a precipitous fall in CRP to 0.36 mg/L. This improvement persisted despite weaning of prednisolone to 5 mg/d and methotrexate to 10 mg/week . Infliximab was ceased after 6 months and at last follow-up—18 months after nivolumab cessation—he continues to have minimal synovitis, well controlled on low-dose methotrexate and prednisolone (5 mg daily) and, critically, no recurrence of his lung cancer.\nInterestingly, in PBMCs and SF collected after 6 months of infliximab therapy, we identified a near restoration (compared with RA) of PD-1 expressing CD4 +memory T-cell frequency .", + "fulltext_subclaims": [ + "The patient was a 62-year-old man with metastatic stage IV squamous cell cancer.", + "The patient had no prior history of autoimmune disease.", + "The patient was treated with nivolumab every 2 weeks (3 mg/kg) from July 2016 to April 2017.", + "The treatment resulted in complete clinical remission of his SCC.", + "Nivolumab was ceased in April 2017.", + "The patient developed musculoskeletal irAEs with disabling polyarthritis.", + "The polyarthritis involved shoulders, elbows, proximal interphalangeal joints, and right knee.", + "The polyarthritis was classified as a grade 3 irAE.", + "C reactive protein (CRP) was markedly elevated at 210 mg/L.", + "Rheumatoid factor (RF), anticyclic-citrullinated peptide antibody (ACPA), and HLA-B27 were negative.", + "Radiographs demonstrated no erosive changes.", + "Despite prednisolone, intra-articular corticosteroid, hydroxychloroquine, and methotrexate, his synovitis remained active.", + "The patient underwent arthroscopic ST biopsy of his right knee in November 2017.", + "The biopsy was 200 days following cessation of nivolumab.", + "At arthroscopy, nivolumab-induced synovitis was more severe macroscopically than synovitis in comparator treatment-naïve early RA ST.", + "Several ST biopsies were undertaken from areas of synovitis within the knee.", + "Matched peripheral blood mononuclear cell (PBMC) and SF samples were collected.", + "ST, SF, and PBMC samples from this patient were compared with samples from three treatment-naïve patients with RF and/or ACPA-positive early RA.", + "Additional PBMC and SF samples were collected from the irAE patient at the conclusion of 6 months infliximab therapy.", + "All patients gave written informed consent.", + "ST samples were analyzed using histology and flow cytometry.", + "Histology was performed on serial 5m sections from formalin-fixed paraffin-embedded ST blocks.", + "Sections were stained with H&E or labeled with primary antibodies for immunohistochemistry.", + "Antibody-stained sections were incubated with horseradish peroxidase linked secondary antibody.", + "Colorimetric visualization was performed with 3-amino-9-ethylcarbazole substrate-chromogen or 3,3′-Diaminobenzidine.", + "Nuclear counterstaining was performed with Mayer’s haematoxylin.", + "Whole slide scans were captured on an Olympus VSI120 bright-field microscope at x20 magnification.", + "Semiquantative assessment of staining intensity was performed by two independent assessors.", + "For flow cytometry, fresh ST was dissociated using Milytenyi Tumour Dissociation Kit.", + "Matched SF and whole blood were collected for each patient at arthroscopy.", + "PBMCs were purified using Lymphoprep reagent.", + "Cells were stained for flow cytometry with Zombie UV, CD45RO, PD1, CD3, CD8, CD4, and CD20.", + "Cells were resuspended in 2% fetal calf serum ready for FACS acquisition.", + "Analysis of cytometry data was performed using FlowJo 10.4.", + "IHC inflammatory cell infiltrate pathotype revealed lymphoid pattern in the patient with irAE.", + "One of the RA controls also had a lymphoid pattern.", + "IHC of ST from the patient with irAE revealed infiltrating memory T-cells (CD45RO+).", + "IHC of ST from the patient with irAE revealed extensive CD68 expressing macrophages.", + "There were no detectable B cells in the irAE ST.", + "Two of the RA ST revealed presence of B cells within lymphoid aggregates.", + "The irAE ST displayed abundant TNFα compared with lower levels of IL-6 labeling.", + "We detected abundant levels of PDL-1 labeling in both RA and irAE ST.", + "There was no detectable PD-1 in ST from the patient with irAE.", + "The synovial cellular infiltrate in ST was similar to RA ST.", + "The presence of intense TNFα staining influenced the decision to prescribe Infliximab.", + "We performed multiparameter flow cytometry to characterize infiltrating T-cells.", + "CD4 +T cells were gated and CD45RO and PD-1 expressing cells were identified.", + "Abundant memory T-cell infiltration was observed in both ST and SF compartments for RA and irAE samples.", + "PBMCs exhibited lower memory T-cell frequency.", + "There was a 20-fold reduction of PD-1 +memory T cells in the SF compartment of irAE samples compared with RA.", + "There was a 4-fold reduction in the ST compartment of irAE samples compared with RA.", + "We observed complete ablation of PD-1 labeling in irAE PBMC memory T-cells.", + "Commencement of infliximab led to a dramatic clinical response.", + "CRP fell to 0.36 mg/L.", + "Improvement persisted despite weaning of prednisolone and methotrexate.", + "Infliximab was ceased after 6 months.", + "At last follow-up, the patient had minimal synovitis.", + "The patient was on low-dose methotrexate and prednisolone.", + "There was no recurrence of his lung cancer.", + "After 6 months of infliximab therapy, PD-1 expressing CD4 +memory T-cell frequency was nearly restored compared with RA." + ], + "summary": "We provide the first report of comparative, parallel ST and synovial fluid (SF) analyses of severe, cDMARD-refractory, seronegative polyarthritis, classified as a grade 3 irAE occurring in response to nivolumab treatment for metastatic squamous cell lung cancer, in comparison with ST and SF from patients with untreated rheumatoid arthritis (RA). We investigated immunohistochemical labeling of ST cytokine expression as a biological rationale for selecting therapy. Flow cytometric analysis of lymphocytes from ST, SF and blood collected before and after synovial biopsy-guided therapy, in comparison with RA, were evaluated for insights into the immunopathogenesis of irAE. Immunolabeling of ST demonstrated an excess of TNFα cytokine expression. Subsequent treatment with infliximab resulted in resolution of inflammatory symptoms and a significant reduction in C reactive protein levels. Flow cytometric analysis of synovial infiltrates indicated absence of programmed cell death protein-1 (PD-1) receptor positivity despite cessation of nivolumab approximately 200 days prior to the analyzes.", + "summary_subclaims": [ + "This is the first report of comparative, parallel synovial tissue (ST) and synovial fluid (SF) analyses of severe, cDMARD-refractory, seronegative polyarthritis.", + "The polyarthritis was classified as a grade 3 immune-related adverse event (irAE) occurring in response to nivolumab treatment for metastatic squamous cell lung cancer.", + "The analyses compared ST and SF from the irAE case with those from patients with untreated rheumatoid arthritis (RA).", + "Immunohistochemical labeling of ST cytokine expression was investigated as a biological rationale for selecting therapy.", + "Flow cytometric analysis of lymphocytes from ST, SF, and blood collected before and after synovial biopsy-guided therapy was evaluated.", + "The flow cytometric analysis was compared with RA for insights into the immunopathogenesis of irAE.", + "Immunolabeling of ST demonstrated an excess of TNFα cytokine expression.", + "Subsequent treatment with infliximab resulted in resolution of inflammatory symptoms.", + "Subsequent treatment with infliximab resulted in a significant reduction in C reactive protein levels.", + "Flow cytometric analysis of synovial infiltrates indicated absence of programmed cell death protein-1 (PD-1) receptor positivity.", + "Nivolumab was discontinued approximately 200 days prior to the flow cytometric analysis." + ] + }, + { + "id": "multiclinsum_test_2646_en.txt", + "fulltext": "A 53-month-old Sudanese female presented with progressive bilateral breast enlargement and accelerated growth since the age of 9 months. Her family had sought medical advice several times in different primary health care facilities and were reassured. She had no vaginal bleeding and no pubic or axillary hair.\nExamination showed a well-looking girl, vitally stable with normal blood pressure. Her weight was 17 kg (50th centile) and height 108 cm (90th centile) using the Centers for Disease Control and Prevention growth chart. Mid-parental height was 175 cm and predicted adult height was 167 cm using the JM Tanner formula. No previous documented follow-up growth data were available. Her Tanner staging was A1, P1, and B3. She had reddish mucoid vagina. She had no clitoromegaly, acne, hirsutism, or palpable abdominal mass .\nLeft wrist X-ray revealed a bone age of 8 years.\nThe hormonal evaluation using fluorometric enzyme immunoassay showed basal luteinizing hormone of 3.1 mIU/L, which increased to 8.8 mIU/L 45 minutes post-gonadotrophin-releasing hormone stimulation. Elevated levels of estradiol E2 29,000 pg/ml (5–15 pg/ml), and dehydroepiandrosterone sulfate 90 ng/mL (2.3 ng/mL), with normal early morning cortisol level 16 ng/mL (7–28 ng/mL). Due to financial difficulties, we did not measured the follicular-stimulating hormone level.\nAbdominal ultrasound revealed a right-sided hypoechoic suprarenal mass, an ovarian volume of 1.8 cm3, uterine volume of 3 cm3, and endometrial thickness of 1.2 cm. The abdominal CT scan showed a 25 × 22 mm well-defined rounded focal lesion with a smooth outline, at the level of the right adrenal gland with homogeneous attenuation, HU-7 on a noncontrast scan, and no evidence of local tissue invasion . The left adrenal gland and ovaries were normal.\nBrain magnetic resonance imaging was done to exclude a central cause of precocious puberty and was normal. Complete hemogram, liver, and renal functions were normal.\nA diagnosis of an estrogen-secreting right adrenocortical tumor was made, and we referred the patient to surgery.\nDuring laparotomy a 3 cm diameter tumor in the right adrenal gland was completely excised. The histopathological examination showed well-circumscribed tumor forming nests with trabeculae and sheets of polygonal cells with eosinophilic cytoplasm. The tumor was not infiltrating the capsule, with no mitosis, atypia, or necrosis (Wieneke index score = 0). Findings suggestive of benign adrenal cortical adenoma.\nThe postoperative evaluation revealed normal cortisol and dehydroepiandrosterone sulfate. Estradiol E2 40 pg/mL was consistent with secondary central precocious puberty, so the patient was started on monthly gonadotrophin-releasing hormone agonist, with a regular follow-up plan for the possibility of recurrence of adrenal adenoma.\nSix months after the operation, the patient was well and compliant to monthly gonadotrophin agonist injections. She showed partial regression of her secondary sexual characters and a growth velocity of 5 cm/year. The abdominal CT scan was normal with no evidence of recurrence.", + "fulltext_subclaims": [ + "The patient is a 53-month-old Sudanese female.", + "She had progressive bilateral breast enlargement and accelerated growth since the age of 9 months.", + "Her family had sought medical advice several times in different primary health care facilities.", + "She had no vaginal bleeding.", + "She had no pubic or axillary hair.", + "Her weight was 17 kg (50th centile).", + "Her height was 108 cm (90th centile) using the Centers for Disease Control and Prevention growth chart.", + "Mid-parental height was 175 cm.", + "Predicted adult height was 167 cm using the JM Tanner formula.", + "No previous documented follow-up growth data were available.", + "Tanner staging was A1, P1, and B3.", + "She had reddish mucoid vagina.", + "Left wrist X-ray revealed a bone age of 8 years.", + "Basal luteinizing hormone was 3.1 mIU/L.", + "Luteinizing hormone increased to 8.8 mIU/L 45 minutes post-gonadotrophin-releasing hormone stimulation.", + "Estradiol E2 was 29,000 pg/ml.", + "Dehydroepiandrosterone sulfate was 90 ng/mL.", + "Early morning cortisol level was 16 ng/mL.", + "Follicular-stimulating hormone level was not measured due to financial difficulties.", + "Abdominal ultrasound revealed a right-sided hypoechoic suprarenal mass.", + "The abdominal CT scan showed a 25 × 22 mm well-defined rounded focal lesion at the level of the right adrenal gland.", + "The left adrenal gland and ovaries were normal.", + "Brain magnetic resonance imaging was done to exclude a central cause of precocious puberty.", + "Brain magnetic resonance imaging was normal.", + "A diagnosis of an estrogen-secreting right adrenocortical tumor was made.", + "The patient was referred to surgery.", + "During laparotomy, a 3 cm diameter tumor in the right adrenal gland was completely excised.", + "Histopathological examination showed well-circumscribed tumor forming nests with trabeculae and sheets of polygonal cells with eosinophilic cytoplasm.", + "The tumor was not infiltrating the capsule.", + "There was no mitosis, atypia, or necrosis.", + "Wieneke index score was 0.", + "Findings were suggestive of benign adrenal cortical adenoma.", + "Postoperative evaluation revealed normal cortisol and dehydroepiandrosterone sulfate.", + "Estradiol E2 was 40 pg/mL.", + "The patient was started on monthly gonadotrophin-releasing hormone agonist.", + "Six months after the operation, the patient was well and compliant to monthly gonadotrophin agonist injections.", + "She showed partial regression of her secondary sexual characters.", + "Growth velocity was 5 cm/year.", + "Abdominal CT scan was normal with no evidence of recurrence." + ], + "summary": "We report a case of a 4-year-old Sudanese girl who presented with gradually progressive bilateral breast enlargement and accelerated growth since the age of 6 months. The family had sought medical advice several times in numerous health facilities without much gain. Investigations showed pubertal luteinizing hormone levels, high estradiol E2, and dehydroepiandrosterone sulfate, with normal early morning cortisol level. Abdominal ultrasound revealed a right-sided hypoechoic suprarenal mass. Abdominal computed tomography scan showed a right adrenal mass. The diagnosis of feminizing adrenal neoplasm was confirmed and right adrenalectomy was done. Histopathological examination of the resected adrenal gland showed adrenocortical adenoma. The patient was started on gonadotrophin-releasing hormone agonist for secondary central precocious puberty.", + "summary_subclaims": [ + "The patient is a 4-year-old Sudanese girl.", + "She had gradually progressive bilateral breast enlargement.", + "She had accelerated growth since the age of 6 months.", + "The family had sought medical advice in numerous health facilities.", + "Investigations showed pubertal luteinizing hormone levels.", + "Investigations showed high estradiol E2.", + "Investigations showed high dehydroepiandrosterone sulfate.", + "The early morning cortisol level was normal.", + "Abdominal ultrasound revealed a right-sided hypoechoic suprarenal mass.", + "Abdominal computed tomography scan showed a right adrenal mass.", + "The diagnosis of feminizing adrenal neoplasm was confirmed.", + "Right adrenalectomy was done.", + "Histopathological examination of the resected adrenal gland showed adrenocortical adenoma.", + "The patient was started on gonadotrophin-releasing hormone agonist." + ] + }, + { + "id": "multiclinsum_test_2804_en.txt", + "fulltext": "A 38-year old white female with type 1 diabetes mellitus complicated by retinopathy, gastroparesis and end-stage renal disease (ESRD) underwent deceased donor SPK transplantation in November of 2007. Cytomegalovirus (CMV) serology was negative in both donor and recipient. Patient was not sensitized and received perioperative induction therapy with rabbit-antithymocyte globulin followed by maintenance immunosuppression with tacrolimus (dose adjusted for targeted trough level of 8-10 ng/mL during first year, 6-8 ng/mL during second year and 4-7 ng/mL subsequently) and mycophenolate mofetil (500 mg twice daily) with early steroid withdrawal. Trimethoprim/sulfamethoxazole (400/80 mg) once daily was used for prophylaxis against Pneumocystis jiroveci infection. Allografts started functioning soon after transplantation without delayed graft function. Serum creatinine stabilized at 1.3 mg/dL and patient remained euglycemic. Six years later, serum creatinine increased to 1.8 mg/d with a blood urea nitrogen level of 20 mg/dL. Urinalysis showed evidence for proteinuria and microhematuria. Other pertinent laboratory values were as follows: WBC 3.29 µ/mL, hemoglobin 10.7 g/dL, platelets 209 µ/mL, serum albumin 3.7 g/dL, serum total cholesterol 167 mg/dL, fasting blood glucose 102 mg/dL, and trough tacrolimus level 5.4 ng/mL, along with negative CMV, BK virus and Epstein-Barr virus PCR. She had proteinuria of 5 g/d. Patient underwent extensive work-up. Serum ANA, anti-double-stranded DNA, cryoglobulins, rheumatoid factor, anti-streptolysin O, proteinase-3 and myeloperoxidase ANCA, as well as hepatitis B and C antibodies were negative. Levels of serum complements and immunoglobulins were normal and no monoclonal bands were observed on serum and urine immunofixation electrophoresis. Serum free light chain assay revealed elevated free kappa (33.8 mg/dL, normal range 3.3-19.4) and normal lambda (25.1 mg/dL, normal range 5.7-26.3) fractions. Patient subsequently underwent kidney allograft biopsy. Light microscopy showed increased mesangial matrix and hypercellularity. Immunofluorescence revealed mesangial 2+ staining for IgG with specificity for IgG3 subclass, C3, C1q, IgM and 1+ staining for kappa light chains with negative staining for lambda light chain, IgA and subclasses of IgG1, IgG2 and IgG4 as well as peritubular capillary C4d. On electron microscopy, abundant mesangial granular electron dense deposits without substructures were seen. These findings were consistent with a diagnosis of PGMNID .\nWe opted for conservative treatment in our patient. She was initiated on lisinopril which she tolerated well. She remained normotensive. Her serum creatinine remains at 1.8 mg/dL with <100 mg/d proteinuria 14 months later.", + "fulltext_subclaims": [ + "The patient is a 38-year old white female.", + "The patient has type 1 diabetes mellitus.", + "The patient has retinopathy.", + "The patient has gastroparesis.", + "The patient has end-stage renal disease.", + "The patient underwent deceased donor SPK transplantation in November of 2007.", + "Cytomegalovirus serology was negative in both donor and recipient.", + "The patient was not sensitized.", + "The patient received perioperative induction therapy with rabbit-antithymocyte globulin.", + "The patient received maintenance immunosuppression with tacrolimus.", + "The tacrolimus trough level target was 8-10 ng/mL during the first year.", + "The tacrolimus trough level target was 6-8 ng/mL during the second year.", + "The tacrolimus trough level target was 4-7 ng/mL subsequently.", + "The patient received mycophenolate mofetil 500 mg twice daily.", + "The patient had early steroid withdrawal.", + "Trimethoprim/sulfamethoxazole 400/80 mg once daily was used for prophylaxis against Pneumocystis jiroveci infection.", + "Allografts started functioning soon after transplantation without delayed graft function.", + "Serum creatinine stabilized at 1.3 mg/dL.", + "The patient remained euglycemic.", + "Six years later, serum creatinine increased to 1.8 mg/dL.", + "Urinalysis showed evidence for proteinuria.", + "Urinalysis showed evidence for microhematuria.", + "The patient had proteinuria of 5 g/d.", + "Serum ANA was negative.", + "Serum anti-double-stranded DNA was negative.", + "Serum cryoglobulins were negative.", + "Serum rheumatoid factor was negative.", + "Serum anti-streptolysin O was negative.", + "Serum proteinase-3 ANCA was negative.", + "Serum myeloperoxidase ANCA was negative.", + "Hepatitis B antibodies were negative.", + "Hepatitis C antibodies were negative.", + "Serum free light chain assay revealed elevated free kappa.", + "Serum free light chain assay revealed normal lambda.", + "The patient underwent kidney allograft biopsy.", + "Light microscopy showed increased mesangial matrix.", + "Light microscopy showed hypercellularity.", + "Immunofluorescence revealed mesangial 2+ staining for IgG.", + "Immunofluorescence revealed mesangial 2+ staining for IgG3 subclass.", + "Immunofluorescence revealed mesangial 2+ staining for C3.", + "Immunofluorescence revealed mesangial 2+ staining for C1q.", + "Immunofluorescence revealed mesangial 2+ staining for IgM.", + "Immunofluorescence revealed 1+ staining for kappa light chains.", + "Immunofluorescence revealed negative staining for lambda light chains.", + "Immunofluorescence revealed negative staining for IgA.", + "Immunofluorescence revealed negative staining for IgG1.", + "Immunofluorescence revealed negative staining for IgG2.", + "Immunofluorescence revealed negative staining for IgG4.", + "Immunofluorescence revealed negative staining for peritubular capillary C4d.", + "Electron microscopy showed abundant mesangial granular electron dense deposits.", + "Electron microscopy showed no substructures.", + "The findings were consistent with a diagnosis of PGMNID.", + "The patient was initiated on lisinopril.", + "The patient remained normotensive.", + "The patient's serum creatinine remained at 1.8 mg/dL.", + "The patient's proteinuria was <100 mg/d 14 months later." + ], + "summary": "A 38-year old female with type 1 diabetes who underwent successful simultaneous pancreas-kidney (SPK) transplantation 6 years earlier presented with rising serum creatinine, nephrotic range proteinuria and microhematuria. She underwent extensive work up and kidney allograft biopsy revealed mesangial expansion and hypercelluarity on light microscopy, mesangial staining for IgG3, kappa light chains, C1q and C3 on immunofluorescence and abundant mesangial electron dense deposits without substructures on electron microscopy. Serum and urine immunofixation electrophoresis were negative. A diagnosis of de novo PGNMID was made. Patient's proteinuria improved and serum creatinine stabilized with conservative therapy.", + "summary_subclaims": [ + "The patient is a 38-year old female with type 1 diabetes.", + "The patient underwent successful simultaneous pancreas-kidney (SPK) transplantation 6 years earlier.", + "The patient presented with rising serum creatinine.", + "The patient had nephrotic range proteinuria.", + "The patient had microhematuria.", + "Kidney allograft biopsy revealed mesangial expansion and hypercellularity on light microscopy.", + "Immunofluorescence showed mesangial staining for IgG3, kappa light chains, C1q and C3.", + "Electron microscopy showed abundant mesangial electron dense deposits without substructures.", + "Serum and urine immunofixation electrophoresis were negative.", + "A diagnosis of de novo PGNMID was made.", + "The patient's proteinuria improved with conservative therapy.", + "The patient's serum creatinine stabilized with conservative therapy." + ] + }, + { + "id": "multiclinsum_test_415_en.txt", + "fulltext": "A 42-year-old woman with history of SLE on hydroxychloroquine, mycophenolate and prednisone, complicated by pancytopenia, presented with severe back pain 30 min after taking oral TMP-SMX 800-160 mg for paronychia. She was found to be febrile to 39.1 °C, hypotensive at 88/63 mmHg, and tachycardic at 107 BPM. Laboratory testing revealed a white blood cell (WBC) count of 8.63 × 103/uL (97.3% neutrophils, 0.1% eosinophils, 0.2% lymphocytes, with a baseline WBC of 2 × 103/uL), lactate 2.3 mmol/L and creatinine of 1.3 mg/dL (baseline 0.7 mg/dL) . HIV ELISA was negative but the CD4+ count was low at 64 cells/uL. Computed tomography (CT) angiogram of the chest showed no evidence of pulmonary embolus or infection and urinalysis was not suggestive of infection. Physical exam was significant for diffusely erythematous and warm skin without macules, papules, or urticaria. There were no other focal findings on physical exam. The patient was initially managed with aggressive 80 mL/kg intravenous (IV) fluid resuscitation, norepinephrine, broad-spectrum antibiotics (IV vancomycin and IV piperacillin-tazobactam), and stress dose steroids (hydrocortisone 50 mg IV every 6 h). Her hypotension resolved quickly over the first 36 h of admission. Over the following 3 days blood and urine cultures remained negative and steroids, vasopressors and antibiotics were discontinued without recurrence of hypotension. Additional infectious work up, including hepatitis B, hepatitis C and toxoplasma, were negative. The patient was discharged home on hospital day four with pneumocystis jirovecii pneumonia (PJP) prophylaxis with atovaquone.\nTen months prior, the patient had a similar presentation several hours after taking her second dose of oral TMP-SMX 800-160 mg, which was prescribed for an abscess of the mons pubis. On presentation, she was hypotensive, tachycardic and febrile. Laboratory testing revealed a WBC of 10.9 × 103/uL (95.5% neutrophils, 0.6% lymphocytes and 0.5% eosinophils), acute kidney injury (creatinine 1.1 mg/dL) and lactate of 1.2 mmol/L. She was treated similarly for presumed septic shock. Work-up for infectious etiologies including blood and urine cultures, CT imaging of head, spine and abdomen as well as an echocardiogram was unrevealing. She was weaned off vasopressor support within 24 h. Her steroids and antibiotics were discontinued within 72 h with clinical improvement and she was discharged home with the diagnosis of septic shock with unknown etiology.", + "fulltext_subclaims": [ + "The patient is a 42-year-old woman.", + "She has a history of systemic lupus erythematosus.", + "She was taking hydroxychloroquine, mycophenolate, and prednisone.", + "She had pancytopenia.", + "She presented with severe back pain 30 minutes after taking oral trimethoprim-sulfamethoxazole 800-160 mg.", + "The trimethoprim-sulfamethoxazole was prescribed for paronychia.", + "She was febrile to 39.1 °C.", + "She was hypotensive at 88/63 mmHg.", + "She was tachycardic at 107 BPM.", + "The white blood cell count was 8.63 × 103/uL.", + "The baseline white blood cell count was 2 × 103/uL.", + "The lactate level was 2.3 mmol/L.", + "The creatinine was 1.3 mg/dL.", + "The baseline creatinine was 0.7 mg/dL.", + "The CD4+ count was 64 cells/uL.", + "The HIV ELISA was negative.", + "The CT angiogram of the chest showed no evidence of pulmonary embolus.", + "The CT angiogram of the chest showed no evidence of infection.", + "The urinalysis was not suggestive of infection.", + "The physical exam showed diffusely erythematous and warm skin.", + "There were no macules, papules, or urticaria.", + "The patient was managed with 80 mL/kg intravenous fluid resuscitation.", + "The patient received norepinephrine.", + "The patient received intravenous vancomycin.", + "The patient received intravenous piperacillin-tazobactam.", + "The patient received hydrocortisone 50 mg intravenously every 6 hours.", + "Her hypotension resolved over the first 36 hours of admission.", + "Blood and urine cultures remained negative over the following 3 days.", + "Steroids, vasopressors, and antibiotics were discontinued without recurrence of hypotension.", + "Hepatitis B, hepatitis C, and toxoplasma testing were negative.", + "The patient was discharged home on hospital day four.", + "The patient was started on pneumocystis jirovecii pneumonia prophylaxis with atovaquone.", + "Ten months prior, the patient had a similar presentation after taking her second dose of oral trimethoprim-sulfamethoxazole 800-160 mg.", + "The trimethoprim-sulfamethoxazole was prescribed for an abscess of the mons pubis.", + "She was hypotensive, tachycardic, and febrile.", + "The white blood cell count was 10.9 × 103/uL.", + "The creatinine was 1.1 mg/dL.", + "The lactate level was 1.2 mmol/L.", + "She was treated similarly for presumed septic shock.", + "Infectious work-up including blood and urine cultures, CT imaging of head, spine, and abdomen, and an echocardiogram was unrevealing.", + "She was weaned off vasopressor support within 24 hours.", + "Steroids and antibiotics were discontinued within 72 hours.", + "She was discharged home with the diagnosis of septic shock with unknown etiology." + ], + "summary": "We present a 42-year-old woman with a history of systemic lupus erythematosus (SLE) who was admitted to the Intensive Care Unit (ICU) twice with fever and circulatory shock after taking a dose of TMP-SMX 800-160 mg. She had no respiratory distress, urticarial rash or eosinophilia on presentation. Infectious workup during both admissions was negative and treatment with antibiotics, steroids and vasopressors was de-escalated with clinical improvement. She was found to be HIV negative, however, labs revealed a low CD4+ count.", + "summary_subclaims": [ + "The patient is a 42-year-old woman.", + "She has a history of systemic lupus erythematosus.", + "She was admitted to the ICU twice.", + "She had fever and circulatory shock after taking a dose of TMP-SMX 800-160 mg.", + "She had no respiratory distress on presentation.", + "She had no urticarial rash on presentation.", + "She had no eosinophilia on presentation.", + "Infectious workup during both admissions was negative.", + "Treatment with antibiotics, steroids, and vasopressors was de-escalated with clinical improvement.", + "She was found to be HIV negative.", + "Labs revealed a low CD4+ count." + ] + }, + { + "id": "multiclinsum_test_90_en.txt", + "fulltext": "A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation . A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.\nWith a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection .\nWith confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.\nAn uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.\nTimeline", + "fulltext_subclaims": [ + "The patient is a 30 year old male.", + "The patient presented with a discharging wound in the upper part of the abdomen for 1 month.", + "The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college.", + "A small peptic perforation was detected and was repaired with an omental patch.", + "On the fourth post-operative day the patient developed burst abdomen.", + "It was managed conservatively.", + "Over a period of time the bowel got contained.", + "The patient was put on oral nutrition.", + "The patient was discharged and was doing fine at home.", + "The abdominal wound was not healing.", + "In the fourth month it was covered with the split thickness skin graft.", + "The procedure and the post-operative period was uneventful till one month.", + "In the fifth month a serous discharge from the upper part of the grafted surface was noticed.", + "It was coming from a small ulcer and was small in amount.", + "Over the period of time till he presented at our OPD it remained small in output.", + "It was managed by applying gauge pieces over the wound.", + "The examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen.", + "There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze.", + "A scar was seen at previous drain site.", + "Palpation of the abdomen showed deficient abdominal wall below the skin graft.", + "Haemoglobin was 11.4 gm/dl.", + "The total WBC count was 11.6 × 103/mm3.", + "The total serum protein was 7.9 gm/dl.", + "The serum albumin was 3.5 gm/dl.", + "A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound.", + "An upper GI endoscopy was performed.", + "A small benign looking ulcer was seen at the pylorus of the stomach.", + "A CT fistulogram was performed.", + "An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen.", + "A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection.", + "A repeat surgery was planned.", + "The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards.", + "Dense interbowel adhesions were encountered.", + "Meticulous adhesiolysis and dissection was performed.", + "The abscess cavity was drained.", + "The perforation on the pylorus of the stomach was identified.", + "It was around 1 cm × 1 cm size.", + "Repeat omental patch repair was performed.", + "Feeding jejunostomy and retrograde tube duodenostomy were also made.", + "An uneventful recovery happened.", + "He attended follow up clinic till 4 months following the discharge.", + "There was an incisional hernia.", + "After this he was lost to follow up." + ], + "summary": "We are presenting a case of peptic perforation repair where burst abdomen happened in the immediate post-operative period. The patient was put on conservative management. He responded well to it but his abdominal wound was not healing. After a wait of four months the wound was covered with a skin graft. The graft uptake was satisfactory but a discharging ulcer appeared on it. This condition persisted for one month. Finally a computed tomography Fistulogram (CT Fistulogram) was performed. It revealed an underlying complex gastric fistula. A repeat surgery was performed.", + "summary_subclaims": [ + "This is a case of peptic perforation repair.", + "Burst abdomen occurred in the immediate post-operative period.", + "The patient was put on conservative management.", + "The patient responded well to conservative management.", + "The abdominal wound was not healing.", + "After a wait of four months, the wound was covered with a skin graft.", + "The graft uptake was satisfactory.", + "A discharging ulcer appeared on the skin graft.", + "This condition persisted for one month.", + "A computed tomography Fistulogram (CT Fistulogram) was performed.", + "The CT Fistulogram revealed an underlying complex gastric fistula.", + "A repeat surgery was performed." + ] + }, + { + "id": "multiclinsum_test_2411_en.txt", + "fulltext": "A 52-year-old woman, gravida-3, para-3, 3 years post-menopausal, presented with post-menopausal bleeding of “several weeks” duration. She ultimately underwent a biopsy on which a diagnosis of endometrioid adenocarcinoma, FIGO grade 1 was rendered. Imaging showed a left adnexal mass whose features were equivocal regarding benignancy. A decision was made to perform a total hysterectomy and bilateral salpingo-oophorectomy. An intraoperative pathologic assessment was performed, which showed the adnexal mass to be benign but the endometrial mass to be of large volume (a 9 × 6 cm soft polypoid mass that occupied the entirety of the uterine cavity) with myometrial invasion and lower uterine segment involvement. A bilateral pelvic lymphadenectomy was also performed. Microscopic examination of the permanent sections of the case showed a grade 1 endometrioid carcinoma of the endometrium, with 35% invasion of the myometrial wall thickness, focal lymphovascular invasion, and metastases to 2 of 16 pelvic lymph nodes . Approximately 40% of the tumor was comprised of columnar glands showing more nuclear stratification, more nuclear enlargement, and more prominent nucleolomegaly than the background glands (atypical areas). These areas also showed comparatively increased mitotic indices (average 17 MF/10 HPF) than the background glands (average 9 MF/10 HPF), from which they were spatially distinct. Immunohistochemically, the atypical areas showed a p53 aberrant immunophenotype, characterized by diffuse and marked nuclear positivity for p53 in more than 90% of lesional nuclei. The p53-aberrant areas were also p16-diffusely positive, vimentin-positive, Napsin A-negative, estrogen receptor positive, and progesterone receptor-positive . The remainder of the tumor (60% of tumoral volume) displayed a p53-wild type immunophenotype, and were p16-mosaic positive, vimentin-positive, Napsin A-negative, estrogen receptor positive, and progesterone receptor-positive. As such, the p53-aberrant and p53-wild type areas showed an identical immunophenotype with the exception of the latter being p16-mosaic positive. Foci of lymphovascular invasion and myometrial invasion showed a p53-wild type immunophenotype and were identical in immunophenotype to the other p53-wild type areas within the tumor. Areas of background hyperplasia showed a p53 wild type immunophenotype. The endometrioid carcinoma at its primary site showed minor squamous differentiation, and no solid components in both the p53-wild type and p53-aberrant areas.\nThe 2 lymph nodes with metastatic disease each showed a distinct biphasic pattern, comprised of both p53-wild type and p53-aberrant areas in foci that were spatially apposed but not intermixed. The p53-aberrant areas were identical in morphology and immunophenotype to the “atypical areas” of the endometrial tumor described above. The p53-wild type tumoral areas were comprised of glands with less columnar configuration and more non-specific cytoplasmic clarity. However, they showed foci of squamous differentiation and were otherwise immunophenotypically identical to the p53-wild type areas within the endometrial tumor . All components of the tumor at both the primary and metastatic sites showed loss of MSH2 and MSH6 with retained expression of MLH1 and PMS2. The patient declined germ-line testing, and underwent adjuvant chemotherapy. The case is too recent for meaningful follow-up.\nAll immunohistochemical studies were performed on 4 μ-thick, unstained slides of formalin-fixed, paraffin-embedded tissue sections using the Ventana Benchmark automation and the Ultra View detection kit (Ventana Medical Systems, Tucson, AZ) and the following primary antibodies: Estrogen receptor (ER; Clone SP1; prediluted, Ventana), Progesterone receptor (PR; clone IE2; prediluted; Ventana), p53 (clone DO-7; dilution 1:40; Ventana), Napsin-A (polyclonal, prediluted; Cell Marque, Rocklin, CA), Vimentin (clone V9, dilution 1: 1000, Ventana), p16 (Clone JC8, prediluted, Santa-Cruz, Dallas, TX), MLH1 (clone G168–15, prediluted, Biocare Medical, Concord, CA), PMS2 (Clone A16–4; dilution 1:25; BD Biosciences, San Jose, CA), MSH2 (clone FE11, prediluted, Biocare Medical), and MSH6 (clone BC/44, prediluted, Biocare Medical).", + "fulltext_subclaims": [ + "The patient is a 52-year-old woman.", + "She is gravida-3 and para-3.", + "She is 3 years post-menopausal.", + "She presented with post-menopausal bleeding of several weeks duration.", + "A biopsy diagnosed endometrioid adenocarcinoma, FIGO grade 1.", + "Imaging showed a left adnexal mass with equivocal benignancy.", + "A total hysterectomy and bilateral salpingo-oophorectomy were performed.", + "Intraoperative pathologic assessment showed the adnexal mass to be benign.", + "The endometrial mass was 9 × 6 cm in size.", + "The endometrial mass occupied the entirety of the uterine cavity.", + "The endometrial mass showed myometrial invasion.", + "The endometrial mass showed lower uterine segment involvement.", + "A bilateral pelvic lymphadenectomy was performed.", + "Microscopic examination showed grade 1 endometrioid carcinoma.", + "The tumor showed 35% myometrial invasion.", + "The tumor showed focal lymphovascular invasion.", + "Metastases were present in 2 of 16 pelvic lymph nodes.", + "Approximately 40% of the tumor showed more nuclear stratification than background glands.", + "The atypical areas showed increased mitotic indices compared to background glands.", + "The atypical areas showed diffuse and marked nuclear positivity for p53 in more than 90% of lesional nuclei.", + "The atypical areas were p16-diffusely positive.", + "The atypical areas were vimentin-positive.", + "The atypical areas were Napsin A-negative.", + "The atypical areas were estrogen receptor positive.", + "The atypical areas were progesterone receptor-positive.", + "The remainder of the tumor showed a p53-wild type immunophenotype.", + "The remainder of the tumor was p16-mosaic positive.", + "The remainder of the tumor was vimentin-positive.", + "The remainder of the tumor was Napsin A-negative.", + "The remainder of the tumor was estrogen receptor positive.", + "The remainder of the tumor was progesterone receptor-positive.", + "The p53-aberrant and p53-wild type areas showed an identical immunophenotype with the exception of p16 expression.", + "Foci of lymphovascular invasion showed a p53-wild type immunophenotype.", + "The endometrioid carcinoma showed minor squamous differentiation.", + "The tumor showed no solid components in both p53-wild type and p53-aberrant areas.", + "The 2 lymph nodes with metastatic disease showed a biphasic pattern.", + "The p53-aberrant areas in lymph nodes were identical in morphology and immunophenotype to the atypical areas of the endometrial tumor.", + "The p53-wild type tumoral areas in lymph nodes showed glands with less columnar configuration.", + "The p53-wild type tumoral areas in lymph nodes showed foci of squamous differentiation.", + "All components of the tumor showed loss of MSH2 and MSH6.", + "All components of the tumor showed retained expression of MLH1 and PMS2.", + "The patient declined germ-line testing.", + "The patient underwent adjuvant chemotherapy.", + "The case is too recent for meaningful follow-up." + ], + "summary": "A low grade endometrioid carcinoma, 9 cm in greatest dimension, with 35% invasion of the myometrial wall thickness, focal lymphovascular invasion, and metastases to 2 of 16 pelvic lymph nodes, was diagnosed in a 52-year-old woman. The endometrial tumor showed a p53-mutation (aberrant)-type immunohistochemical pattern in 40% of the tumor, but the rest of the tumor, as well as the foci of myometrial and lymphovascular invasion, were p53-wild type. Both lymph nodes with metastatic disease showed a distinct biphasic pattern, comprised of both p53-wild type and p53-aberrant areas in tumoral foci that were spatially apposed but not intermixed. Most p53-aberrant areas (at both the lymph nodes and the endometrium) showed a higher mitotic index and increased atypia as compared to the p53-wild type areas; both showed squamous differentiation. The p53-aberrant areas at both locations were also p16-diffusely positive, vimentin-positive, and estrogen/progesterone receptor-positive, whereas the p53-wild type areas showed an identical immunophenotype with the exception of being p16-mosaic positive. All components of the tumor at both the primary and metastatic sites showed loss of MSH2 and MSH6 and retained MLH/PMS2 expression.", + "summary_subclaims": [ + "The tumor was a low grade endometrioid carcinoma.", + "The tumor was 9 cm in greatest dimension.", + "The tumor had 35% invasion of the myometrial wall thickness.", + "The tumor had focal lymphovascular invasion.", + "The tumor had metastases to 2 of 16 pelvic lymph nodes.", + "The tumor showed a p53-mutation (aberrant)-type immunohistochemical pattern in 40% of the tumor.", + "The rest of the tumor, as well as the foci of myometrial and lymphovascular invasion, were p53-wild type.", + "Both lymph nodes with metastatic disease showed a distinct biphasic pattern.", + "The biphasic pattern in the lymph nodes comprised both p53-wild type and p53-aberrant areas.", + "The p53-aberrant areas showed a higher mitotic index as compared to the p53-wild type areas.", + "The p53-aberrant areas showed increased atypia as compared to the p53-wild type areas.", + "Both p53-aberrant and p53-wild type areas showed squamous differentiation.", + "The p53-aberrant areas were p16-diffusely positive.", + "The p53-wild type areas showed p16-mosaic positivity.", + "All components of the tumor showed loss of MSH2 and MSH6.", + "All components of the tumor retained MLH/PMS2 expression." + ] + }, + { + "id": "multiclinsum_test_2915_en.txt", + "fulltext": "A 73-year-old male patient presented with a firm, subcutaneous nodule in the right upper eyelid . The lesion was present for 10 years, slowly growing and painless. The mass was round, relatively hard and moved freely under the skin, without pain on palpation or mobilization. The overlying skin showed no inflammatory signs or abnormal pigmentation. There was no restriction in ocular movements, and the remaining ophthalmological examinations were unremarkable.\nThe patient underwent an orbital CT scan that revealed an extra-conical mass, adjacent to the lateral rectus insertion, with no distortion of the globe or invasion of the bone or muscular structures. The mass had a heterogeneous density, and two cysts were present in its superoanterior portion .\nAn excisional biopsy was performed over the upper eyelid dermis, through a 15 mm horizontal incision in the lateral third of the eyelid crease. The tumor was well circumscribed with no adhesions and was easily dissected and removed in its entirety . The lacrimal gland was found to be independent of the mass, with a normal appearance. The incision was closed with a 6.0 polypropylene suture. The postoperative appearance can be observed in .\nOn gross pathologic examination, the nodule was well-defined with dimensions 20 mm × 15 mm × 12 mm. A smooth and tan cutting surface was found, with tiny cavitated areas containing a pasty whitish material. The entire specimen was submitted to histologic examination. The tumor was totally encapsulated and presented a biphasic pattern, consisting of a chondromyxoid stroma and an epithelial component . The epithelium was arranged in nests, cords, and tubes, or glandular branching structures layered by a double epithelium in which the inner epithelial layer exhibited apocrine features, such as decapitation [Figure and ]. There was no significant atypia. Numerous cysts were present in the tumor, lined by metaplastic stratified squamous epithelium and containing keratinized epithelial plugs in the lumen . No areas of necrosis, interstitial hemorrhage or appreciable mitotic activity were found. No satellite nodules were identified. Immunohistochemistry revealed a variable expression of the inner epithelial cells to pancytokeratins AE1/AE3 and to carcinoembryonic antigen (CEA) [Figure and ]. The outer epithelial cells and stromal component expressed vimentin and S100 protein [Figure and ]. There was no evidence of lacrimal gland parenchyma or signs of malignant changes. These findings defined the tumor as a palpebral pleomorphic adenoma and were consistent with apocrine differentiation.\nThe systemic work-up was negative for metastasis; thus the patient was kept under vigilance with periodic observations. In 2 years of follow-up, he has remained asymptomatic without the signs of local recurrence.", + "fulltext_subclaims": [ + "The patient is a 73-year-old male.", + "The patient had a firm, subcutaneous nodule in the right upper eyelid.", + "The lesion was present for 10 years.", + "The mass was round, relatively hard, and moved freely under the skin.", + "The overlying skin showed no inflammatory signs or abnormal pigmentation.", + "There was no restriction in ocular movements.", + "The remaining ophthalmological examinations were unremarkable.", + "An orbital CT scan revealed an extra-conical mass adjacent to the lateral rectus insertion.", + "The mass had a heterogeneous density.", + "Two cysts were present in the superoanterior portion of the mass.", + "An excisional biopsy was performed over the upper eyelid dermis.", + "The tumor was well circumscribed with no adhesions.", + "The tumor was easily dissected and removed in its entirety.", + "The lacrimal gland was found to be independent of the mass.", + "The incision was closed with a 6.0 polypropylene suture.", + "On gross pathologic examination, the nodule was well-defined with dimensions 20 mm × 15 mm × 12 mm.", + "The tumor was totally encapsulated and presented a biphasic pattern.", + "The tumor consisted of a chondromyxoid stroma and an epithelial component.", + "The epithelium was arranged in nests, cords, and tubes, or glandular branching structures.", + "The inner epithelial layer exhibited apocrine features.", + "Numerous cysts were present in the tumor, lined by metaplastic stratified squamous epithelium.", + "No areas of necrosis, interstitial hemorrhage, or appreciable mitotic activity were found.", + "No satellite nodules were identified.", + "Immunohistochemistry revealed variable expression of the inner epithelial cells to pancytokeratins AE1/AE3.", + "The outer epithelial cells and stromal component expressed vimentin and S100 protein.", + "There was no evidence of lacrimal gland parenchyma or signs of malignant changes.", + "The tumor was defined as a palpebral pleomorphic adenoma.", + "The findings were consistent with apocrine differentiation.", + "The systemic work-up was negative for metastasis.", + "The patient was kept under vigilance with periodic observations.", + "In 2 years of follow-up, the patient remained asymptomatic without signs of local recurrence." + ], + "summary": "A 73-year-old male patient presented with a nodular mass on the lateral third of his right upper eyelid, which had slowly enlarged over 10 years. Radiologic features were of an extra-conical mass, with no invasion of adjacent structures. An excisional biopsy of the lesion was performed. The histopathological examination revealed a biphasic tumor, composed of tubules with a double layer of epithelial cells arranged in a chondromyxoid stroma. The inner epithelial cells were positive for pancytokeratins AE1/AE3 and carcinoembryonic antigen. The outer epithelial cells and stromal component expressed vimentin and S100 protein. These pathologic findings were consistent with a palpebral pleomorphic adenoma, with an apocrine gland origin.", + "summary_subclaims": [ + "The patient is a 73-year-old male.", + "The patient had a nodular mass on the lateral third of his right upper eyelid.", + "The mass had slowly enlarged over 10 years.", + "Radiologic features were of an extra-conical mass.", + "There was no invasion of adjacent structures.", + "An excisional biopsy of the lesion was performed.", + "The histopathological examination revealed a biphasic tumor.", + "The tumor was composed of tubules with a double layer of epithelial cells arranged in a chondromyxoid stroma.", + "The inner epithelial cells were positive for pancytokeratins AE1/AE3.", + "The inner epithelial cells were positive for carcinoembryonic antigen.", + "The outer epithelial cells and stromal component expressed vimentin.", + "The outer epithelial cells and stromal component expressed S100 protein.", + "The pathologic findings were consistent with a palpebral pleomorphic adenoma.", + "The tumor was suggested to have an apocrine gland origin." + ] + }, + { + "id": "multiclinsum_test_2924_en.txt", + "fulltext": "A six-month-old boy (weight 6.3 kg) presented to our hospital with episodes of supraventricular tachycardia (SVT), tachypnea, and left ventricular dysfunction. The presence of ALCAPA was not initially recognized, and our patient's left ventricular dysfunction was attributed to SVT. He was eventually diagnosed with ALCAPA on the basis of echocardiography and multi-slice computed tomography (CT) . Τhe suspicion of probable ALCAPA was raised after his third echocardiographic examination and was confirmed by a CT scan. The left coronary artery originated from the leftward-facing sinus of the pulmonary valve. The left ventricle was dilated with an ejection fraction of 30%. Our patient underwent direct re-implantation of the left coronary artery to the aorta using the trapdoor flap technique (cross-clamp time 92 minutes, bypass time 137 minutes). He started having recurrent episodes of SVT, with a heart rate of 220 beats/minute immediately after extubation on the second post-operative day. The episodes were converted to sinus rhythm with adenosine or rapid atrial pacing, thus ruling out junctional ectopic tachycardia. Despite treatment with amiodarone, the episodes continued. Propranolol, digoxin, and propafenone were added at maximal tolerated doses without success. An electrophysiological study was performed in the fourth post-operative week using a 5-French decapolar catheter placed into the left subclavian vein in the coronary sinus (CS), a 4-French bipolar catheter placed from the left femoral vein into the right ventricle, and a 5-French mapping/ablation catheter placed through the right femoral vein. Atrioventricular re-entry tachycardia was induced reproducibly with programmed atrial stimulation, with a tachycardia cycle length of 250 milliseconds and earlier retrograde atrial depolarization recorded by the distal bipole of the CS catheter. Access to the left atrium was achieved by using a trans-septal approach , and mapping was performed during tachycardia using a non-fluoroscopic navigation system (Ensite-NavX; St Jude Medical, St Paul, MN, USA). Tachycardia stopped 2.7 seconds after the onset of the fourth application of RF energy . The total fluoroscopy time was 24.7 minutes, maximum power was 30W, maximum temperature was 58°C, and the total procedure duration was four hours. Post-ablation aortography revealed patency of the left coronary artery without stenosis of the circumflex coronary artery. There was no recurrence of the SVT while our patient was in a drug-free state at the six-month follow-up examination.", + "fulltext_subclaims": [ + "The patient was a six-month-old boy weighing 6.3 kg.", + "The patient presented with episodes of supraventricular tachycardia.", + "The patient had tachypnea.", + "The patient had left ventricular dysfunction.", + "The presence of ALCAPA was not initially recognized.", + "The patient's left ventricular dysfunction was attributed to SVT.", + "The patient was eventually diagnosed with ALCAPA.", + "The diagnosis was based on echocardiography and multi-slice computed tomography.", + "The suspicion of probable ALCAPA was raised after the third echocardiographic examination.", + "The diagnosis was confirmed by a CT scan.", + "The left coronary artery originated from the leftward-facing sinus of the pulmonary valve.", + "The left ventricle was dilated.", + "The ejection fraction was 30%.", + "The patient underwent direct re-implantation of the left coronary artery to the aorta.", + "The trapdoor flap technique was used.", + "The cross-clamp time was 92 minutes.", + "The bypass time was 137 minutes.", + "The patient started having recurrent episodes of SVT immediately after extubation on the second post-operative day.", + "The episodes were converted to sinus rhythm with adenosine or rapid atrial pacing.", + "Junctional ectopic tachycardia was ruled out.", + "Despite treatment with amiodarone, the episodes continued.", + "Propranolol, digoxin, and propafenone were added at maximal tolerated doses.", + "An electrophysiological study was performed in the fourth post-operative week.", + "A 5-French decapolar catheter was placed into the left subclavian vein in the coronary sinus.", + "A 4-French bipolar catheter was placed from the left femoral vein into the right ventricle.", + "A 5-French mapping/ablation catheter was placed through the right femoral vein.", + "Atrioventricular re-entry tachycardia was induced reproducibly with programmed atrial stimulation.", + "The tachycardia cycle length was 250 milliseconds.", + "Earlier retrograde atrial depolarization was recorded by the distal bipole of the CS catheter.", + "Access to the left atrium was achieved by using a trans-septal approach.", + "Mapping was performed during tachycardia using a non-fluoroscopic navigation system.", + "Tachycardia stopped 2.7 seconds after the onset of the fourth application of RF energy.", + "The total fluoroscopy time was 24.7 minutes.", + "The maximum power was 30W.", + "The maximum temperature was 58°C.", + "The total procedure duration was four hours.", + "Post-ablation aortography revealed patency of the left coronary artery.", + "There was no stenosis of the circumflex coronary artery.", + "There was no recurrence of the SVT while the patient was in a drug-free state at the six-month follow-up examination." + ], + "summary": "A six-month-old boy from Pakistan was brought to our hospital with tachypnea and supraventricular tachycardia and, on the basis of echocardiography and multi-slice computed tomography, was diagnosed with an anomalous left coronary artery origin from the pulmonary artery. The presence of an anomalous left coronary artery origin from the pulmonary artery was not initially recognized, and left ventricular dysfunction was considered as a result of supraventricular tachycardia. He underwent direct re-implantation of the left coronary artery to the aorta using the trapdoor flap technique. Recurrent episodes of supraventricular tachycardia resistant to maximal pharmacological treatment occurred post-operatively. A left posterolateral accessory pathway was successfully ablated by using a trans-septal approach.", + "summary_subclaims": [ + "A six-month-old boy from Pakistan was brought to our hospital with tachypnea and supraventricular tachycardia.", + "On the basis of echocardiography and multi-slice computed tomography, he was diagnosed with an anomalous left coronary artery origin from the pulmonary artery.", + "The presence of an anomalous left coronary artery origin from the pulmonary artery was not initially recognized.", + "Left ventricular dysfunction was considered as a result of supraventricular tachycardia.", + "He underwent direct re-implantation of the left coronary artery to the aorta using the trapdoor flap technique.", + "Recurrent episodes of supraventricular tachycardia resistant to maximal pharmacological treatment occurred post-operatively.", + "A left posterolateral accessory pathway was successfully ablated by using a trans-septal approach." + ] + }, + { + "id": "multiclinsum_test_84_en.txt", + "fulltext": "A 9-year-old girl was admitted due to repeated loss of consciousness, concomitant with a pale face, palpitations, and convulsions, which had persisted for 2 years and had been aggravated during the previous 2 months. These symptoms occurred automatically. The patient denied experiencing any sweating, nausea, vomiting, trembling, or an obvious sense of hunger before meals. The patient was previously misdiagnosed with epilepsy in another hospital, but no abnormal findings were detected on a 24-h electroencephalogram at our hospital. Her abdominal perfusion CT showed a highly perfused nodule within the pancreatic tail; A magnetic resonance scan confirmed the location of this nodule and indicated that its size was 11.6 × 13.2 mm . Additionally, 68Ga-exendin 4 PET-CT showed a region in the pancreatic tail with abnormally high metabolism and overexpression of the glucagon-like peptide-1 receptor . Lab testing showed a low fasting blood glucose (BG) of 2.2 mmol/L (reference range: 3.9–6.1 mmol/L), a high proinsulin level of 4455.9 pg/mL (reference range: 30–180 ng/mL), a normal C-peptide level of 2.56 ng/mL (reference range: 0.8–4.2 ng/mL), a serum insulin level of 15.35 μIU/mL (reference range: 5.2–17.2 μIU/mL), and a gastrin level of 92.6 pg/mL (reference range: < 100 pg/mL). These results confirmed a diagnosis of insulinoma. Imaging examination showed no abnormalities indicative of parathyroid adenoma or malignancy in the pituitary or adrenal glands. Lab testing showed normal levels of parathyroid hormone (PTH), blood calcium, phosphate, follicle-stimulating hormone (FSH), growth hormone (GH), prolactin (PRL), adrenocorticotropic hormone (ACTH), 24-h urinary free cortisol (24 hUFC), and serum cortisol. Her luteinizing hormone (LH) level was 0.24 IU/L (reference range: 2.12–10 IU/L during the follicular phase), which was considered related to her age.\nPreoperative preparation: To avoid recurrent symptoms and to maintain her fasting BG at a tolerably low level, the patient was given regular snacks before bedtime. BG can be controlled at a level between 50 and 60 mg/dL preoperatively.\nSurgical procedure: The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system with intraoperative ultrasound (IOUS) connected. The patient was put in a head-low, feet-high and left-lateral position. The robotic system was positioned at the head of the patient, while the assistant surgeon stood between the patient’s legs. Abdominal exploration via laparoscopy was conducted, and no obvious abnormalities were found. The robotic lens and operating arms were docked. The gastrocolic ligament was dissected with an ultrasonically activated scalpel. The head of the pancreas was exposed by grasping the colon downward and lifting the stomach. Towards the tail of the pancreas, we separated and exposed the spleen. The surgeon then controlled the ultrasound probe, exploring the tumor from the pancreatic tail to the head and the uncinated process with the assistance of a prograsp clamp. A quasi-circular, hypoechoic lesion was found at the end of the pancreas with a diameter of approximately 10 mm and a clear boundary. We marked the normal pancreatic tissue around the lesion with an electrotome, and while dividing the pancreas sequentially, suction was used continually to visualize the tumor capsule. Precise positioning was achieved using IOUS, and the tumor was completely resected along the capsule . A peritoneal drainage tube was placed. The surgery went well, lasting 65 min (skin to skin), and the volume of intraoperative bleeding was 5 mL. Intraoperative BG is documented in Table .\nAfter surgery, the patient was given liquid diet on POD2. The drain was clean and was removed on POD4, and the patient gradually resumed her normal diet. She was discharged to home on POD6. During the following 1.5 years, the patient had no recurrence of the disease. No postoperative complication occurred, such as pancreatic fistula or pancreatic function deficiency.\nPathological examination showed that the tumor was a pancreatic neuroendocrine tumor (Grade 2 with a Ki-67 index of 4%) . This tumor was positive for CgA, Syn, and AE1/AE3 . Insulin staining was partially positive , while gastrin, glucagon, and somatostatin staining were negative .\nSanger-directed sequencing for the MEN1 gene mutation was performed on a peripheral blood sample, revealing a homozygous pathogenic mutation of c247_250delCTGT (p.Ile85Serfs*33) . This point mutation was also detected in the frozen tissue of the patient.", + "fulltext_subclaims": [ + "The patient is a 9-year-old girl.", + "She was admitted due to repeated loss of consciousness.", + "The symptoms had persisted for 2 years.", + "The symptoms had been aggravated during the previous 2 months.", + "The symptoms occurred automatically.", + "The patient denied experiencing any sweating, nausea, vomiting, trembling, or an obvious sense of hunger before meals.", + "The patient was previously misdiagnosed with epilepsy in another hospital.", + "No abnormal findings were detected on a 24-h electroencephalogram at our hospital.", + "Her abdominal perfusion CT showed a highly perfused nodule within the pancreatic tail.", + "A magnetic resonance scan confirmed the location of this nodule.", + "The size of the nodule was 11.6 × 13.2 mm.", + "68Ga-exendin 4 PET-CT showed a region in the pancreatic tail with abnormally high metabolism.", + "68Ga-exendin 4 PET-CT showed overexpression of the glucagon-like peptide-1 receptor.", + "Lab testing showed a low fasting blood glucose of 2.2 mmol/L.", + "Lab testing showed a high proinsulin level of 4455.9 pg/mL.", + "Lab testing showed a normal C-peptide level of 2.56 ng/mL.", + "Lab testing showed a serum insulin level of 15.35 μIU/mL.", + "Lab testing showed a gastrin level of 92.6 pg/mL.", + "These results confirmed a diagnosis of insulinoma.", + "Imaging examination showed no abnormalities indicative of parathyroid adenoma.", + "Imaging examination showed no abnormalities indicative of malignancy in the pituitary or adrenal glands.", + "Lab testing showed normal levels of parathyroid hormone, blood calcium, phosphate, follicle-stimulating hormone, growth hormone, prolactin, adrenocorticotropic hormone, 24-h urinary free cortisol, and serum cortisol.", + "Her luteinizing hormone level was 0.24 IU/L.", + "Her luteinizing hormone level was considered related to her age.", + "To avoid recurrent symptoms, the patient was given regular snacks before bedtime.", + "BG can be controlled at a level between 50 and 60 mg/dL preoperatively.", + "The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system.", + "Intraoperative ultrasound was connected.", + "The patient was put in a head-low, feet-high and left-lateral position.", + "The robotic system was positioned at the head of the patient.", + "The assistant surgeon stood between the patient’s legs.", + "Abdominal exploration via laparoscopy was conducted.", + "No obvious abnormalities were found.", + "The robotic lens and operating arms were docked.", + "The gastrocolic ligament was dissected with an ultrasonically activated scalpel.", + "The head of the pancreas was exposed by grasping the colon downward and lifting the stomach.", + "Towards the tail of the pancreas, we separated and exposed the spleen.", + "The surgeon controlled the ultrasound probe, exploring the tumor from the pancreatic tail to the head and the uncinated process.", + "A quasi-circular, hypoechoic lesion was found at the end of the pancreas with a diameter of approximately 10 mm.", + "The lesion had a clear boundary.", + "The normal pancreatic tissue around the lesion was marked with an electrotome.", + "The tumor was completely resected along the capsule.", + "A peritoneal drainage tube was placed.", + "The surgery lasted 65 min (skin to skin).", + "The volume of intraoperative bleeding was 5 mL.", + "The patient was given liquid diet on POD2.", + "The drain was clean and was removed on POD4.", + "The patient gradually resumed her normal diet.", + "She was discharged to home on POD6.", + "During the following 1.5 years, the patient had no recurrence of the disease.", + "No postoperative complication occurred, such as pancreatic fistula or pancreatic function deficiency.", + "Pathological examination showed that the tumor was a pancreatic neuroendocrine tumor.", + "The tumor was Grade 2 with a Ki-67 index of 4%.", + "The tumor was positive for CgA, Syn, and AE1/AE3.", + "Insulin staining was partially positive.", + "Gastrin, glucagon, and somatostatin staining were negative.", + "Sanger-directed sequencing for the MEN1 gene mutation was performed on a peripheral blood sample.", + "A homozygous pathogenic mutation of c247_250delCTGT (p.Ile85Serfs*33) was revealed.", + "This point mutation was also detected in the frozen tissue of the patient." + ], + "summary": "We present a case of a 9-year-old girl presenting with repeated loss of consciousness, concomitant with a pale face, palpitations, and convulsions, which had persisted for 2 years and had been aggravated during the previous 2 months. She was previously misdiagnosed with epilepsy in another hospital. We further examined her while she was hospitalized. By combining her medical history and imaging examination and lab test results, a diagnosis of insulinoma was confirmed. Sanger-directed sequencing on a peripheral blood sample revealed an MEN1 gene mutation, indicating pediatric insulinoma with MEN1 syndrome. The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system with intraoperative ultrasound (IOUS) connected. The surgery was successfully completed within 65 min, and the girl recovered well postoperatively and no longer experienced symptoms of hypoglycemia.", + "summary_subclaims": [ + "The patient is a 9-year-old girl.", + "She had repeated loss of consciousness.", + "She had a pale face.", + "She had palpitations.", + "She had convulsions.", + "The symptoms had persisted for 2 years.", + "The symptoms had been aggravated during the previous 2 months.", + "She was previously misdiagnosed with epilepsy in another hospital.", + "A diagnosis of insulinoma was confirmed.", + "Sanger-directed sequencing on a peripheral blood sample revealed an MEN1 gene mutation.", + "The patient underwent minimally invasive insulinoma enucleation surgery.", + "The surgery was performed under the Da Vinci robot-assisted system.", + "Intraoperative ultrasound was connected during the surgery.", + "The surgery was successfully completed within 65 minutes.", + "The girl recovered well postoperatively.", + "The girl no longer experienced symptoms of hypoglycemia." + ] + }, + { + "id": "multiclinsum_test_1790_en.txt", + "fulltext": "A 16-year-old boy is presented complaining of sudden cervicofacial swelling, fever, dyspnea and chest pain one day after dental surgery for an inferior left second molar. During physical examination crepitation and swelling were found in periorbital, cervical and thoracic regions due to subcutaneous emphysema. The patient had no previous heart or lung problems.\nThere was no evidence of airway obstruction or respiratory distress. At the time of admission vital signs were normal and O2 saturation was 98%. White blood cell count revealed leukocytosis and neutrophilia (21000 cells and 84% neutrophils). Chest x-ray showed subcutaneous emphysema in the cervicofacial, thoracic, and axillary regions with no evidence of rib fracture. Pneumomediastinum is seen as a small amount of air adjacent to the aortic arc (a, b). Thoracic CT scan revealed air in the subcutaneous and cervical spaces extending to the mediastinum. Conservative treatment consisted of intravenous antibiotic therapy with Clindamycin, Ceftazidime and bed rest but no oral feeding. In the next days the swelling resolved and control CXR showed a decrease in surgical emphysema and resolution of pneumomediastinum. After five days the patient was discharged. Two days after being discharged, physical examination and chest x-ray were normal. For the next 3 weeks, the patient was examined weekly and no problems were found.", + "fulltext_subclaims": [ + "A 16-year-old boy is presented complaining of sudden cervicofacial swelling, fever, dyspnea and chest pain one day after dental surgery for an inferior left second molar.", + "During physical examination crepitation and swelling were found in periorbital, cervical and thoracic regions due to subcutaneous emphysema.", + "The patient had no previous heart or lung problems.", + "There was no evidence of airway obstruction or respiratory distress.", + "At the time of admission vital signs were normal and O2 saturation was 98%.", + "White blood cell count revealed leukocytosis and neutrophilia (21000 cells and 84% neutrophils).", + "Chest x-ray showed subcutaneous emphysema in the cervicofacial, thoracic, and axillary regions with no evidence of rib fracture.", + "Pneumomediastinum is seen as a small amount of air adjacent to the aortic arc.", + "Thoracic CT scan revealed air in the subcutaneous and cervical spaces extending to the mediastinum.", + "Conservative treatment consisted of intravenous antibiotic therapy with Clindamycin, Ceftazidime and bed rest but no oral feeding.", + "In the next days the swelling resolved and control CXR showed a decrease in surgical emphysema and resolution of pneumomediastinum.", + "After five days the patient was discharged.", + "Two days after being discharged, physical examination and chest x-ray were normal.", + "For the next 3 weeks, the patient was examined weekly and no problems were found." + ], + "summary": "A 16-year-old boy is presented with subcutaneous emphysema and pneumomediastinum which developed 24 hours after surgery for extraction of an inferior second molar. We first describe history, clinical presentation and radiologic appearance of our patient and then review the literature about oral surgery causing pneumomediastinum.", + "summary_subclaims": [ + "A 16-year-old boy is presented with subcutaneous emphysema and pneumomediastinum.", + "The subcutaneous emphysema and pneumomediastinum developed 24 hours after surgery.", + "The surgery was for extraction of an inferior second molar.", + "The text describes the history, clinical presentation, and radiologic appearance of the patient.", + "The text reviews the literature about oral surgery causing pneumomediastinum." + ] + }, + { + "id": "multiclinsum_test_1768_en.txt", + "fulltext": "Three years ago, an 11-year-old girl presented to the hospital with pain in the right jaw after becoming aware of a mass in her right cheek. After detailed examination, the patient was diagnosed with ASPS with primary tumor in the right cheek and multiple lung metastases, and chemotherapeutic treatment was initiated. After receiving 1 cycle of VAC therapy (vincristine [2 mg], actinomycin D [0.045 mg/kg], and cyclophosphamide [1.2 g/m2]), the patient developed grade 4 neutropenia. After this treatment, the patient received 1 cycle of the treatment regimen prescribed for rhabdomyosarcoma (vincristine [2 mg], pirarubicin [60 mg/m2], cyclophosphamide [1.2 g/m2], cisplatin [20 mg/m2]) and 1 cycle of ifosfamide (1800 mg/m2), etoposide (100 mg/m2), actinomycin D (0.045 mg/kg), and vincristine (2 mg); however, the development of severe neutropenia made it difficult to continue administration of these drugs. The patient was then treated with oral administration of 800 mg/day of pazopanib for 1 year, and clinical benefit was achieved. Upon stabilization of the disease, oral administration of pazopanib was discontinued; however, 1 year later, fluorodeoxyglucose accumulation was observed in the right front of the skull (maximum standardized uptake value [SUV-max], 2.8) and in the left breast (SUV-max, 2.4) using fluorodeoxyglucose-positron emission tomography/computed tomography.\nAn elastic, soft tumor, approximately 3 cm in size, was palpated in the lower lateral region of the left breast. Ultrasonography revealed a hypoechoic, internally heterogeneous mass measuring 22.4 × 16.2 × 21.1 mm with a rich blood supply , while magnetic resonance imaging showed a 3-cm sized tumor that was larger than the one found on prior imaging . Examination of a core-needle biopsy specimen from the same site showed proliferating tumor cells with abundant foamy cytoplasm, clear nucleoli, and oval nuclei . The tumor cells tested positive for AE1/AE3, CAM 5.2, vimentin, S-100, α-actin, desmin, and HMB 45. The specimen showed negative periodic acid–Schiff (PAS) staining after diastase digestion ; furthermore, the specimen then tested positive for transcription factor E3, resulting in a pathological diagnosis of ASPS . Based on the above information, we established a diagnosis of ASPS with left mammary, lung, and cranial metastases. Due to chemoresistance, surgical excision was selected as the mode of treatment; resection of the cranial bone showing metastasis was performed first and partial mastectomy of the left breast was performed in two stages. The mammary tumor was 25 mm in size, and the cut surface was solid with a reddish gray color . Histological findings similar to those of the needle biopsy specimen were also obtained in the final pathological diagnosis and resection margins were negative. Postoperative conditions were good, and we are currently monitoring the patient through regular follow-ups (visual palpation every 3 months and semi-annual mammary gland ultrasonography).", + "fulltext_subclaims": [ + "An 11-year-old girl presented to the hospital with pain in the right jaw after becoming aware of a mass in her right cheek.", + "The patient was diagnosed with ASPS with primary tumor in the right cheek and multiple lung metastases.", + "Chemotherapeutic treatment was initiated.", + "After receiving 1 cycle of VAC therapy, the patient developed grade 4 neutropenia.", + "The patient received 1 cycle of the treatment regimen prescribed for rhabdomyosarcoma.", + "The patient received 1 cycle of ifosfamide, etoposide, actinomycin D, and vincristine.", + "The development of severe neutropenia made it difficult to continue administration of these drugs.", + "The patient was then treated with oral administration of 800 mg/day of pazopanib for 1 year.", + "Clinical benefit was achieved.", + "Upon stabilization of the disease, oral administration of pazopanib was discontinued.", + "Fluorodeoxyglucose accumulation was observed in the right front of the skull (SUV-max, 2.8) and in the left breast (SUV-max, 2.4).", + "An elastic, soft tumor, approximately 3 cm in size, was palpated in the lower lateral region of the left breast.", + "Ultrasonography revealed a hypoechoic, internally heterogeneous mass measuring 22.4 × 16.2 × 21.1 mm with a rich blood supply.", + "Magnetic resonance imaging showed a 3-cm sized tumor that was larger than the one found on prior imaging.", + "Examination of a core-needle biopsy specimen showed proliferating tumor cells with abundant foamy cytoplasm, clear nucleoli, and oval nuclei.", + "The tumor cells tested positive for AE1/AE3, CAM 5.2, vimentin, S-100, α-actin, desmin, and HMB 45.", + "The specimen showed negative periodic acid–Schiff (PAS) staining after diastase digestion.", + "The specimen then tested positive for transcription factor E3.", + "A pathological diagnosis of ASPS was made.", + "A diagnosis of ASPS with left mammary, lung, and cranial metastases was established.", + "Surgical excision was selected as the mode of treatment.", + "Resection of the cranial bone showing metastasis was performed first.", + "Partial mastectomy of the left breast was performed in two stages.", + "The mammary tumor was 25 mm in size, and the cut surface was solid with a reddish gray color.", + "Histological findings similar to those of the needle biopsy specimen were also obtained in the final pathological diagnosis.", + "The resection margins were negative.", + "Postoperative conditions were good.", + "The patient is currently being monitored through regular follow-ups (visual palpation every 3 months and semi-annual mammary gland ultrasonography)." + ], + "summary": "Three years ago, an 11-year-old girl presented to the hospital with pain in the right jaw after becoming aware of a mass in the right cheek. After detailed examination, the patient was diagnosed with ASPS with the primary tumor in the right cheek and multiple lung metastases, and chemotherapeutic treatment was initiated. One year later, accumulation of fluorodeoxyglucose (FDG) was observed in the right front of the skull (standardized uptake value (SUV)-max 2.8) and left breast (SUV-max 2.4) using FDG-positron emission tomography (PET) / computed tomography (CT). Ultrasonography revealed the mammary tumor as a hypoechoic, internally heterogeneous mass measuring 22.4 × 16.2 × 21.1 mm with a rich blood supply. Using pathological findings of core-needle biopsy, we diagnosed it as ASPS. Based on the above information, we made a diagnosis of ASPS with left mammary and cranial metastases. Due to chemoresistance, surgical excision was selected as the mode of treatment; resection of the metastatic cranial bone was performed first, and partial mastectomy of the left breast was performed in two stages. Postoperative conditions were good, and we are currently performing regular follow-ups (visual palpation every 3 months and semi-annual mammary gland ultrasonography).", + "summary_subclaims": [ + "Three years ago, an 11-year-old girl presented to the hospital with pain in the right jaw after becoming aware of a mass in the right cheek.", + "The patient was diagnosed with ASPS with the primary tumor in the right cheek and multiple lung metastases.", + "Chemotherapeutic treatment was initiated.", + "One year later, accumulation of fluorodeoxyglucose (FDG) was observed in the right front of the skull (standardized uptake value (SUV)-max 2.8) and left breast (SUV-max 2.4) using FDG-positron emission tomography (PET) / computed tomography (CT).", + "Ultrasonography revealed the mammary tumor as a hypoechoic, internally heterogeneous mass measuring 22.4 × 16.2 × 21.1 mm with a rich blood supply.", + "Using pathological findings of core-needle biopsy, we diagnosed it as ASPS.", + "We made a diagnosis of ASPS with left mammary and cranial metastases.", + "Due to chemoresistance, surgical excision was selected as the mode of treatment.", + "Resection of the metastatic cranial bone was performed first.", + "Partial mastectomy of the left breast was performed in two stages.", + "Postoperative conditions were good.", + "We are currently performing regular follow-ups (visual palpation every 3 months and semi-annual mammary gland ultrasonography)." + ] + }, + { + "id": "multiclinsum_test_1377_en.txt", + "fulltext": "A 53-year-old man with a history of multiple myocardial infarctions was admitted to our hospital because of ADHF accompanied by acute kidney injury (AKI) and hyperkalaemia. On admission, the patient was alert and oriented. Physical examination revealed blood pressure 130/70 mmHg, irregular tachycardia to 143 beats per minute with an oxygen saturation of 94% on room air. Respiratory rate was 26 breaths per minute, and physical examination revealed wheezing rales heard in both lungs and oedema in the lower extremities bilaterally. Due to significant wheezing and irregular tachycardia, abnormal heart sounds were difficult to distinguish on cardiac auscultation. The patient had type 2 diabetes mellitus, chronic kidney disease, paroxysmal AF, and high low-density lipoprotein cholesterol. He was markedly obese with a body weight (BW) of 131 kg [body mass index (BMI) = 45.9 kg/m2]. Laboratory tests showed an increase of brain natriuretic peptide (180.8 pg/mL, normal value: 18.4 < pg/mL), high serum potassium (9.4 mEq/l, normal value: 3.6–4.9 mEq/l). Serum urea nitrogen was 128.7 mg/dL (normal value: 8.0–22.0 mg/dL) and serum creatinine was 5.48 mg/dL (normal value: 0.60–1.10 mg/dL). An emergent continuous haemodialysis/filtration was conducted, and potassium value decreased. An electrocardiogram showed rapid AF rhythm plus ventricular premature beats around the rate of 160 beats per minute with left bundle branch block QRS morphology. The patient’s left ventricle showed marked dilatation and diffuse hypokinesis on echocardiography. The end-diastolic and end-systolic diameters of the left ventricle were 70 and 64 mm, respectively, and the ejection fraction (EF) was 18%. The left atrial diameter was 48 mm. Mild mitral and tricuspid regurgitation were observed. The end-diastolic and end-systolic volumes were 403.9 and 364.2 mL, respectively, evaluated by cardiac magnetic resonance imaging (MRI). The EF on cardiac MRI was 9.8%. Coronary artery angiography was performed 1 month before admission and no significant stenotic lesion was found.\nThe medications were optimized as possible for chronic HF and other co-morbidities, including bisoprolol (2.5 mg), angiotensin II receptor blocker (ARB) (olmesartan 40 mg), vasopressin receptor antagonist (tolvaptan 15 mg), loop diuretics (furosemide 80 mg), mineralocorticoid receptor antagonist (spironolactone 12.5 mg), and amiodarone 200 mg. The maximum dose of ARBs was prescribed whereas dose of beta-blocker and spironolactone were sub-maximum doses due to frequent histories of ADHF/low output state and hyperkalaemia, which required emergent haemodialysis.\nDirect current electrical cardioversion (DC) was repeated under the support of intravenous anti-arrhythmics (amiodarone and nifekalant) to improve the haemodynamic status. However, sinus rhythm could not be maintained, and AF recurred many times. The patient developed a low cardiac output state and multiple organ failure with persisting AF. Intra-aortic balloon pumping (IABP) and mechanical ventilation with intubation were initiated. Right heart catheterization (RHC) on Day 20 showed a mean pulmonary capillary wedge pressure of 57 mmHg and a cardiac index of 2.7 L/min/m2, under the support of IABP and catecholamine infusion (DOA = 4.7 µg/mL/min, DOB = 5 µg/mL/min). On the same day, continuous haemodialysis/filtration (CHDF) was started because of acute kidney injury (AKI) and anuria. One dose of Digoxin was administered intravenously, and intravenous infusion of an ultra-short-acting beta1-selective blocker (randiolol) was used as a rate control strategy. However, rate control of AF was challenging with the heart rate consistently greater than 120 b.p.m. despite sedation, with transient elevation up to 140 b.p.m. On Day 27, the haemodynamic status collapsed to a systolic blood pressure of 50 mmHg. Therefore, our Heart Team decided to perform an emergent catheter ablation of AF to overcome the vicious cycle of HF and AF. Bilateral pulmonary vein isolation (PVI) was performed using the Ensite system and an irrigated-tip ablation catheter (Tacticath, Abbott Laboratories, St Paul, MN, USA) , under deep sedation with dexmedetomidine and thiamylal. Sinus rhythm was restored by DC cardioversion following PVI. The procedure time was 2 h. These procedures were completed without using contrast agents, considering AKI.\nAfter PVI, the sinus rhythm was restored. The patient’s haemodynamic condition improved dramatically, and catecholamine dosage was reduced. On the day after ablation, the IABP was removed. Renal function recovered and the patient began to produce urine. One week later, the patient was extubated, and mechanical ventilation was withdrawn. The patient’s clinical course is summarized in . There was an episode of AF recurrence after ablation, which was resolved by DC. After continuing cardiac rehabilitation program, the patient was discharged on foot, 1.5 months after the ablation.", + "fulltext_subclaims": [ + "The patient was a 53-year-old man.", + "The patient had a history of multiple myocardial infarctions.", + "The patient was admitted to the hospital because of ADHF.", + "The patient had acute kidney injury.", + "The patient had hyperkalaemia.", + "On admission, the patient was alert and oriented.", + "Physical examination revealed blood pressure 130/70 mmHg.", + "Physical examination revealed irregular tachycardia to 143 beats per minute.", + "Oxygen saturation was 94% on room air.", + "Respiratory rate was 26 breaths per minute.", + "Wheezing rales were heard in both lungs.", + "Oedema in the lower extremities was present bilaterally.", + "The patient had type 2 diabetes mellitus.", + "The patient had chronic kidney disease.", + "The patient had paroxysmal AF.", + "The patient had high low-density lipoprotein cholesterol.", + "The patient's body weight was 131 kg.", + "The patient's BMI was 45.9 kg/m2.", + "Brain natriuretic peptide was 180.8 pg/mL.", + "Serum potassium was 9.4 mEq/l.", + "Serum urea nitrogen was 128.7 mg/dL.", + "Serum creatinine was 5.48 mg/dL.", + "An emergent continuous haemodialysis/filtration was conducted.", + "Potassium value decreased after haemodialysis.", + "An electrocardiogram showed rapid AF rhythm.", + "The patient’s left ventricle showed marked dilatation.", + "The left ventricular end-diastolic diameter was 70 mm.", + "The left ventricular end-systolic diameter was 64 mm.", + "The ejection fraction was 18%.", + "The left atrial diameter was 48 mm.", + "Mild mitral and tricuspid regurgitation were observed.", + "The end-diastolic volume was 403.9 mL.", + "The end-systolic volume was 364.2 mL.", + "The EF on cardiac MRI was 9.8%.", + "Coronary artery angiography was performed 1 month before admission.", + "No significant stenotic lesion was found.", + "The medications included bisoprolol 2.5 mg.", + "The medications included olmesartan 40 mg.", + "The medications included tolvaptan 15 mg.", + "The medications included furosemide 80 mg.", + "The medications included spironolactone 12.5 mg.", + "The medications included amiodarone 200 mg.", + "The maximum dose of ARBs was prescribed.", + "The dose of beta-blocker was sub-maximum.", + "The dose of spironolactone was sub-maximum.", + "Direct current electrical cardioversion was repeated.", + "Intravenous anti-arrhythmics were used.", + "Sinus rhythm could not be maintained.", + "AF recurred many times.", + "The patient developed a low cardiac output state.", + "The patient developed multiple organ failure.", + "Intra-aortic balloon pumping was initiated.", + "Mechanical ventilation with intubation was initiated.", + "Right heart catheterization showed a mean pulmonary capillary wedge pressure of 57 mmHg.", + "Right heart catheterization showed a cardiac index of 2.7 L/min/m2.", + "Continuous haemodialysis/filtration was started.", + "One dose of Digoxin was administered intravenously.", + "Intravenous infusion of randiolol was used.", + "Rate control of AF was challenging.", + "The heart rate was consistently greater than 120 b.p.m.", + "The heart rate transiently elevated up to 140 b.p.m.", + "The haemodynamic status collapsed to a systolic blood pressure of 50 mmHg.", + "An emergent catheter ablation of AF was performed.", + "Bilateral pulmonary vein isolation was performed.", + "The Ensite system was used.", + "An irrigated-tip ablation catheter was used.", + "Sinus rhythm was restored by DC cardioversion.", + "The procedure time was 2 h.", + "The procedures were completed without using contrast agents.", + "Sinus rhythm was restored after PVI.", + "The patient’s haemodynamic condition improved.", + "Catecholamine dosage was reduced.", + "The IABP was removed on the day after ablation.", + "Renal function recovered.", + "The patient began to produce urine.", + "The patient was extubated one week later.", + "Mechanical ventilation was withdrawn.", + "There was an episode of AF recurrence after ablation.", + "The AF recurrence was resolved by DC.", + "The patient was discharged 1.5 months after the ablation." + ], + "summary": "A 53-year-old, obese man with a history of myocardial infarction presented to our hospital. Heart function deteriorated with an ejection fraction of 9.8%, and he was repeatedly hospitalized due to worsening HF. This time, the patient was emergently admitted due to ADHF associated with persistent AF. Atrial fibrillation was refractory to electrical cardioversion. Despite optimized medical support, the patient developed haemodynamic collapse and multiple organ failure. Intra-aortic balloon pump (IABP) and mechanical ventilation were initiated in addition to intravenous catecholamines. Emergent AF ablation was performed. Following pulmonary vein isolation, sinus rhythm was restored and the patient's haemodynamic status dramatically improved. The IABP and mechanical ventilation were withdrawn within a few days, and the catecholamine dose was reduced. After cardiac rehabilitation, the patient was discharged.", + "summary_subclaims": [ + "The patient is a 53-year-old, obese man with a history of myocardial infarction.", + "Heart function deteriorated with an ejection fraction of 9.8%.", + "The patient was repeatedly hospitalized due to worsening HF.", + "The patient was emergently admitted due to ADHF associated with persistent AF.", + "Atrial fibrillation was refractory to electrical cardioversion.", + "The patient developed haemodynamic collapse and multiple organ failure.", + "Intra-aortic balloon pump (IABP) and mechanical ventilation were initiated.", + "Emergent AF ablation was performed.", + "Following pulmonary vein isolation, sinus rhythm was restored.", + "The patient's haemodynamic status dramatically improved.", + "The IABP and mechanical ventilation were withdrawn within a few days.", + "The catecholamine dose was reduced.", + "The patient was discharged after cardiac rehabilitation." + ] + }, + { + "id": "multiclinsum_test_923_en.txt", + "fulltext": "A 46-year-old woman presented to our clinic with a right palpable breast mass in January 2022. Ultrasonography (US) revealed a 2.3 × 1.7 × 1.3 cm hypoechoic mass in the right breast at 11 o’clock position, with a BI-RADS category of 4a. Multiple enlarged lymph nodes (LNs) were detected in bilateral axillae. Her past medical history was notable for a low-grade FL under watchful waiting . A retroperitoneal mass was found during a regular health examination in December 2020 and biopsy suggested Grade 1–2 FL. Immunohistochemistry (IHC) revealed positive expression of CD21 (FDC), CD20, CD23, CD10, BCL-2 and BCL-6, as well as negative expression of cyclin D1. Ki-67 index was 20%. A positron emission tomography (PET)-computerized tomography (CT) scan demonstrated significant uptake (SUVmax 7.6) in the retroperitoneal LN, measuring 4.1 × 2.9 cm. Bilateral axillary, left parasternal, paravertebral, intraabdominal, intrapelvic, and bilateral inguinal LNs were also 18F-fluorodeoxyglucose (FDG)-avid. She remained in good performance status and asymptomatic under close surveillance by her hematologist for over a year.\nThe patient was immediately suggested an open biopsy or core biopsy to determine the nature of the right breast mass. However, she refused due to personal reasons. In October 2022, the patient presented with a large mass in her right breast with skin involvement. She also suffered from recurrent fevers with headache, chills, and joint pain since August 2022, followed by short of breath and rapid progression of the right breast mass. US showed an 8.3 × 3.6 × 4.1 cm mass in the right breast, with lymphadenopathy at all three levels of bilateral axillae. Whole-body PET-CT demonstrated a hypermetabolic mass in the right breast and hypermetabolic LNs on both sides of the diaphragm. Increased 18F-FDG activity was also detected in enlarged spleen and bone marrow . Biopsy of the right breast mass was then performed and the pathological examination revealed no special type, histological grade 3 TNBC with a Ki-67 index of 70% . Blood test revealed significantly high white blood cell (WBC 114.28×109/L) and lymphocyte counts (LY 106.73×109/L), low hemoglobin (HGB 97g/L), and an elevated lactate dehydrogenase (LDH) of 443 U/L. Abnormal serum tumor markers including CA19-9 of 189.2 U/mL, CA125 of 938.0 U/mL, and CA15-3 of 183.5 U/mL were also detected. Bone marrow aspiration and biopsy confirmed bone marrow infiltration by FL ( and ). Therefore, stage IV FL with a FLIPI score of 4 and locally advanced TNBC were confirmed and both were indicated for systemic therapy.\nThe patient subsequently underwent neoadjuvant therapy with R-CHOP (rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone). After two cycles of R-CHOP, the right breast mass decreased from 8.5 × 6.7 cm to 4.9 × 5.6 cm based on CT examination ( and ), showing a partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. WBC, LY, and LDH decreased to normal limits. CA15-3 descended to 99.3 U/mL. However, the mass in the right breast increased rapidly after the completion of the third cycle of R-CHOP ( and ). Next-generation sequencing (NGS) performed on the breast tumor sample revealed a HRD score of 72 and pathogenic mutations in ARID1A, FBXW7, SLX4, and TP53 genes. According to the NGS results, the neoadjuvant regimen was changed to R-TP (rituximab, nab-paclitaxel, and cisplatin). The patient responded well to the R-TP regimen with a rapid reduction in tumor size, from 7.4 × 8.7 cm to 3.9 × 3.7 cm ( and ). After three cycles of R-TP, CA15-3 descended to 51.8 U/mL. PET-CT was performed again and showed that hypermetabolic LNs on both sides of the diaphragm decreased in size as well as 18F-FDG uptake. A significant decrease in size and 18F-FDG uptake was also detected in spleen .\nThe patient then underwent right modified radical mastectomy and right axillary LN dissection. The pathological examination of right axillary LNs demonstrated both LN metastases from TNBC (1/50) and FL infiltration (49/50) . The pathological staging of TNBC was T3N1M0, IIIA. After surgery, the patient continued to receive R-TP for 3 cycles and adjuvant radiotherapy for breast cancer.", + "fulltext_subclaims": [ + "A 46-year-old woman presented to our clinic with a right palpable breast mass in January 2022.", + "Ultrasonography (US) revealed a 2.3 × 1.7 × 1.3 cm hypoechoic mass in the right breast at 11 o’clock position.", + "The mass was assigned a BI-RADS category of 4a.", + "Multiple enlarged lymph nodes (LNs) were detected in bilateral axillae.", + "Her past medical history was notable for a low-grade FL under watchful waiting.", + "A retroperitoneal mass was found during a regular health examination in December 2020.", + "Biopsy suggested Grade 1–2 FL.", + "Immunohistochemistry (IHC) revealed positive expression of CD21 (FDC), CD20, CD23, CD10, BCL-2 and BCL-6.", + "Immunohistochemistry (IHC) revealed negative expression of cyclin D1.", + "Ki-67 index was 20%.", + "A positron emission tomography (PET)-computerized tomography (CT) scan demonstrated significant uptake (SUVmax 7.6) in the retroperitoneal LN, measuring 4.1 × 2.9 cm.", + "Bilateral axillary, left parasternal, paravertebral, intraabdominal, intrapelvic, and bilateral inguinal LNs were also 18F-fluorodeoxyglucose (FDG)-avid.", + "She remained in good performance status and asymptomatic under close surveillance by her hematologist for over a year.", + "The patient was immediately suggested an open biopsy or core biopsy to determine the nature of the right breast mass.", + "She refused the biopsy due to personal reasons.", + "In October 2022, the patient presented with a large mass in her right breast with skin involvement.", + "She also suffered from recurrent fevers with headache, chills, and joint pain since August 2022.", + "She also suffered from short of breath and rapid progression of the right breast mass.", + "US showed an 8.3 × 3.6 × 4.1 cm mass in the right breast.", + "Whole-body PET-CT demonstrated a hypermetabolic mass in the right breast.", + "Hypermetabolic LNs were detected on both sides of the diaphragm.", + "Increased 18F-FDG activity was also detected in enlarged spleen and bone marrow.", + "Biopsy of the right breast mass was then performed.", + "The pathological examination revealed no special type, histological grade 3 TNBC with a Ki-67 index of 70%.", + "Blood test revealed significantly high white blood cell (WBC 114.28×109/L) and lymphocyte counts (LY 106.73×109/L).", + "Blood test revealed low hemoglobin (HGB 97g/L).", + "An elevated lactate dehydrogenase (LDH) of 443 U/L was detected.", + "Abnormal serum tumor markers including CA19-9 of 189.2 U/mL, CA125 of 938.0 U/mL, and CA15-3 of 183.5 U/mL were also detected.", + "Bone marrow aspiration and biopsy confirmed bone marrow infiltration by FL.", + "Stage IV FL with a FLIPI score of 4 and locally advanced TNBC were confirmed.", + "Both were indicated for systemic therapy.", + "The patient subsequently underwent neoadjuvant therapy with R-CHOP.", + "After two cycles of R-CHOP, the right breast mass decreased from 8.5 × 6.7 cm to 4.9 × 5.6 cm based on CT examination.", + "The mass showed a partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1.", + "WBC, LY, and LDH decreased to normal limits.", + "CA15-3 descended to 99.3 U/mL.", + "The mass in the right breast increased rapidly after the completion of the third cycle of R-CHOP.", + "Next-generation sequencing (NGS) performed on the breast tumor sample revealed a HRD score of 72.", + "NGS revealed pathogenic mutations in ARID1A, FBXW7, SLX4, and TP53 genes.", + "The neoadjuvant regimen was changed to R-TP.", + "The patient responded well to the R-TP regimen with a rapid reduction in tumor size, from 7.4 × 8.7 cm to 3.9 × 3.7 cm.", + "After three cycles of R-TP, CA15-3 descended to 51.8 U/mL.", + "PET-CT showed that hypermetabolic LNs on both sides of the diaphragm decreased in size as well as 18F-FDG uptake.", + "A significant decrease in size and 18F-FDG uptake was also detected in spleen.", + "The patient then underwent right modified radical mastectomy and right axillary LN dissection.", + "The pathological examination of right axillary LNs demonstrated both LN metastases from TNBC (1/50) and FL infiltration (49/50).", + "The pathological staging of TNBC was T3N1M0, IIIA.", + "After surgery, the patient continued to receive R-TP for 3 cycles.", + "The patient received adjuvant radiotherapy for breast cancer." + ], + "summary": "A 46-year-old woman, already suffering a history of untreated, advanced-stage, high tumor burden FL, was admitted for a rapidly progressing right breast mass. Ultrasonography showed an 8.3 × 3.6 × 4.1 cm fungating mass in the right breast with enlarged lymph nodes (LNs) in bilateral axillae. PET-CT demonstrated increased 18F- FDG activity in right breast mass, LNs on both sides of the diaphragm, enlarged spleen, and bone marrow. Biopsy of the right breast mass revealed TNBC. The patient underwent neoadjuvant therapy with R-CHOP and achieved partial response of breast tumor. However, TNBC progressed after three cycles of R-CHOP. According to the next-generation sequencing (NGS) assay on breast mass showing a homologous recombination repair (HRR) deficiency (HRD) score of 72, the neoadjuvant regimen was changed to rituximab plus nab-paclitaxel and cisplatin (R-TP) and resulted in significant tumor regression. The patient then underwent right mastectomy with an axillary LN dissection. After the surgery, she was regularly monitored and given adjuvant therapy with R-TP and radiotherapy.", + "summary_subclaims": [ + "The patient is a 46-year-old woman.", + "The patient has a history of untreated, advanced-stage, high tumor burden follicular lymphoma.", + "The patient was admitted for a rapidly progressing right breast mass.", + "Ultrasonography showed an 8.3 × 3.6 × 4.1 cm fungating mass in the right breast.", + "PET-CT demonstrated increased 18F-FDG activity in the right breast mass.", + "Biopsy of the right breast mass revealed triple-negative breast cancer.", + "The patient underwent neoadjuvant therapy with R-CHOP.", + "The patient achieved partial response of the breast tumor after R-CHOP.", + "TNBC progressed after three cycles of R-CHOP.", + "Next-generation sequencing of the breast mass showed an HRR deficiency score of 72.", + "The neoadjuvant regimen was changed to rituximab plus nab-paclitaxel and cisplatin.", + "The change in regimen resulted in significant tumor regression.", + "The patient underwent right mastectomy with axillary lymph node dissection.", + "The patient received adjuvant therapy with R-TP and radiotherapy." + ] + }, + { + "id": "multiclinsum_test_2396_en.txt", + "fulltext": "A man in his late 60s with a history of Stage I melanoma of the upper thigh, for which he had undergone wide local excision and negative sentinel lymph node biopsy 2 years prior, presented with new metastatic disease. On imaging, he was found to have lesions of the lung, liver, vertebrae, and brain. Fine needle aspiration of a thoracic lymph node confirmed metastatic melanoma. Next generation sequencing was notable for BRAF V600E mutation.\nThe patient started treatment with combination ipilimumab and nivolumab. While undergoing immunotherapy, the patient also received radiation to his T7-T10 vertebral metastases (30 Gray (Gy) in 10 fractions) and had stereotactic radiosurgery (SRS) to 16 brain metastases. Spinal irradiation was performed with a 3D conformal technique using opposed anterior-posterior/ posterior-anterior fields. The maximum dose to the spinal canal was 33.5 Gy.\nMagnetic resonance imaging (MRI) of the brain following SRS showed marked treatment response. Re-staging computed tomography (CT) of the chest, abdomen, and pelvis, performed 2 months after his initial staging scans, also showed major systemic response. Prior to starting his fourth cycle of ipilimumab and nivolumab, the patient noted the onset of intermittent numbness and tingling of the soles of his feet, with gradual ascension to his knees over the next 2 months.\nMRI brain 1 month later showed a new punctate cerebellar metastasis, which was treated using SRS. Positron emission tomography (PET)/CT demonstrated resolution of numerous hyper-metabolic lesions with a remaining area of increased focal uptake in the left ischial tuberosity . Given evidence of disease progression in the ischial tuberosity but not other systemic areas, the patient transitioned to pembrolizumab and received radiation to his ischial lesion. Approximately 2 weeks after starting pembrolizumab, the patient noted gait instability and ataxia, and further ascension of numbness to the level of his hips. At that time, he was still able to ambulate independently with the assistance of walking sticks. One month after starting pembrolizumab, the patient presented to the emergency department (ED) with 1 day of urinary retention and fecal incontinence. A spinal MRI was performed which showed T2 signal abnormality and patchy enhancement in the thoracic spinal cord (T5 to T10) concerning for myelitis or radiation necrosis without evidence of tumor or malignant cord compression. The T2 signal abnormality corresponded with the thoracic spinal radiation field . Given that the lesion was enhancing and initially confined to the radiation field, radiation necrosis was favored at that time.\nThe patient’s immunotherapy was discontinued, steroids (dexamethasone 8 mg twice daily) were initiated, and two doses of bevacizumab (for possible radiation necrosis) were administered, without improvement. Lumbar puncture was deferred due to recent bevacizumab. Given the lack of improvement to optimal therapy for radiation necrosis, transverse myelitis was then favored. Results of serologic evaluation of metabolic (vitamin B12, thyroid stimulating hormone), infectious (human immunodeficiency virus, rapid plasma reagin), and autoimmune (anti-nuclear antibodies, anti-Ro/La, aquaporin-4 immunoglobulin G, erythrocyte sedimentation rate, C-reactive protein) etiologies of transverse myelitis were normal. The patient was trialed on high-dose intravenous methylprednisolone (1000 mg daily for 5 days) for transverse myelitis. His lower extremity numbness and gait instability progressed and he started plasmapheresis.\nFollowing 15 sessions of plamapheresis, a dose of cyclophosphamide 1000 mg/m2 was added but the patient continued to decline with worsening urinary retention, bilateral lower extremity spasticity, and complete loss of lower extremity sensation to T5. He did not have upper extremity involvement. Cerebrospinal fluid (CSF) analysis at that time was remarkable for elevated protein (total protein, 99 mg/dL; institutional normal range, 15–45 mg/dL) and negative for malignant cells. Myelin basic protein was elevated at 31.6 ng/mL (normal < 5.5), and oligoclonal bands were matched in the serum and CSF, consistent with an ongoing systemic immune reaction. CSF albumin index was mildly elevated, suggestive of slight impairment of the blood-CSF barrier. Serum studies for antibodies to human T-lymphotropic virus (HTLV) I and II, and a paraneoplastic panel (anti-NR1, anti-GAD65, anti-alpha 3AChR, anti-LGI1, anti-VGCC, anti-VGKC, anti-CASPR2, anti-amphiphysin, anti-CV2, anti-Hu, anti-Ma, anti-Ta, anti-recoverin, anti-Ri, anti-Yo, anti-Zic4) were negative. A serum IL-6 level was normal. A serum TNF-alpha level was not obtained. MRI of the brain demonstrated two new intracranial metastases. MRI of the spine showed progression of transverse myelitis from T3 to T11 , now clearly outside the radiation field. Body PET/CT revealed worsening osseous metastatic lesions; therefore the patient began dabrafenib and trametinib. Given his ascending transverse myelitis despite optimal therapy other options including tocilizumab and infliximab were considered. Based on the low IL-6 level, the patient was started on infliximab. Spinal MRI 3 weeks after the first dose of infliximab showed a dramatic reduction of the level of the T2 cord signal abnormality back to T6 to T10 with corresponding improvement in sensory level and muscle spasms. Continued treatment with infliximab led to additional incremental gains on imaging but without further clinical improvement. He subsequently developed systemic progression on dabrafenib and tremetinib (but with stable central nervous system disease) and ultimately succumbed to his disease.", + "fulltext_subclaims": [ + "The patient is a man in his late 60s.", + "He had a history of Stage I melanoma of the upper thigh.", + "He had undergone wide local excision and negative sentinel lymph node biopsy 2 years prior.", + "He presented with new metastatic disease.", + "Imaging showed lesions of the lung, liver, vertebrae, and brain.", + "Fine needle aspiration of a thoracic lymph node confirmed metastatic melanoma.", + "Next generation sequencing was notable for BRAF V600E mutation.", + "He started treatment with combination ipilimumab and nivolumab.", + "He received radiation to his T7-T10 vertebral metastases (30 Gray (Gy) in 10 fractions).", + "He had stereotactic radiosurgery (SRS) to 16 brain metastases.", + "Spinal irradiation was performed with a 3D conformal technique using opposed anterior-posterior/posterior-anterior fields.", + "The maximum dose to the spinal canal was 33.5 Gy.", + "MRI of the brain following SRS showed marked treatment response.", + "Re-staging CT showed major systemic response.", + "Prior to starting his fourth cycle of ipilimumab and nivolumab, the patient noted the onset of intermittent numbness and tingling of the soles of his feet.", + "MRI brain 1 month later showed a new punctate cerebellar metastasis, which was treated using SRS.", + "PET/CT demonstrated resolution of numerous hyper-metabolic lesions with a remaining area of increased focal uptake in the left ischial tuberosity.", + "Given evidence of disease progression in the ischial tuberosity but not other systemic areas, the patient transitioned to pembrolizumab.", + "Approximately 2 weeks after starting pembrolizumab, the patient noted gait instability and ataxia.", + "One month after starting pembrolizumab, the patient presented to the ED with 1 day of urinary retention and fecal incontinence.", + "Spinal MRI showed T2 signal abnormality and patchy enhancement in the thoracic spinal cord (T5 to T10) concerning for myelitis or radiation necrosis.", + "The T2 signal abnormality corresponded with the thoracic spinal radiation field.", + "Radiation necrosis was favored at that time.", + "The patient’s immunotherapy was discontinued.", + "Steroids (dexamethasone 8 mg twice daily) were initiated.", + "Two doses of bevacizumab were administered.", + "Lumbar puncture was deferred due to recent bevacizumab.", + "Transverse myelitis was then favored.", + "Results of serologic evaluation of metabolic, infectious, and autoimmune etiologies of transverse myelitis were normal.", + "The patient was trialed on high-dose intravenous methylprednisolone (1000 mg daily for 5 days).", + "His lower extremity numbness and gait instability progressed.", + "He started plasmapheresis.", + "Following 15 sessions of plasmapheresis, a dose of cyclophosphamide 1000 mg/m2 was added.", + "He continued to decline with worsening urinary retention, bilateral lower extremity spasticity, and complete loss of lower extremity sensation to T5.", + "CSF analysis was remarkable for elevated protein (total protein, 99 mg/dL).", + "Myelin basic protein was elevated at 31.6 ng/mL.", + "Oligoclonal bands were matched in the serum and CSF.", + "CSF albumin index was mildly elevated.", + "Serum studies for antibodies to HTLV I and II were negative.", + "A serum IL-6 level was normal.", + "MRI of the brain demonstrated two new intracranial metastases.", + "MRI of the spine showed progression of transverse myelitis from T3 to T11.", + "Body PET/CT revealed worsening osseous metastatic lesions.", + "The patient began dabrafenib and trametinib.", + "He was started on infliximab.", + "Spinal MRI 3 weeks after the first dose of infliximab showed a dramatic reduction of the level of the T2 cord signal abnormality back to T6 to T10.", + "He subsequently developed systemic progression on dabrafenib and trametinib.", + "He ultimately succumbed to his disease." + ], + "summary": "We report a case of a 68-year-old with metastatic melanoma, who developed transverse myelitis in the setting of immune checkpoint blockade and spinal irradiation for vertebral metastases. Despite management according to published consensus guidelines: cessation of immune therapy, high-dose steroids, and plasmapheresis, he continued to deteriorate neurologically, and imaging revealed a progressive and ascending transverse myelitis. The patient was then treated with infliximab, and demonstrated dramatic imaging and modest clinical improvement following the first treatment cycle.", + "summary_subclaims": [ + "The patient was a 68-year-old with metastatic melanoma.", + "The patient developed transverse myelitis.", + "The transverse myelitis occurred in the setting of immune checkpoint blockade.", + "The transverse myelitis occurred in the setting of spinal irradiation for vertebral metastases.", + "Management included cessation of immune therapy.", + "Management included high-dose steroids.", + "Management included plasmapheresis.", + "The patient continued to deteriorate neurologically.", + "Imaging revealed a progressive and ascending transverse myelitis.", + "The patient was treated with infliximab.", + "The patient demonstrated dramatic imaging improvement following the first treatment cycle.", + "The patient demonstrated modest clinical improvement following the first treatment cycle." + ] + }, + { + "id": "multiclinsum_test_1127_en.txt", + "fulltext": "A 19-month-old girl with no known immunocompromise presented with persistent unilateral neck lumps two weeks after lacerating her chin on a wooden shelving unit. While the laceration and swelling had healed uneventfully without specific therapy, neck swelling and overlying erythema developed following her injury, further increasing over the following four weeks. An ultrasound revealed several mild to moderately enlarged left submandibular and upper cervical lymph nodes—changes in keeping with inflammation.\nExamination revealed two prominent lymph nodes on the left side of her neck but was otherwise unremarkable. An 18 mm lymph node was located in the submandibular area, and another node (22 mm) towards the tail of her parotid . Both were fluctuant with erythema of the overlying and surrounding skin. There were no fistulae present. Incision and drainage with curettage was performed under general anaesthesia. Copious purulent discharge was drained and sent along with tissue for histological review and culture. A full blood count performed was within normal limits and C-reactive protein was not elevated. A ten-day course of Clarithromycin 150 mg twice daily was taken post-operatively. The wound healed without complication and no further therapy was required.", + "fulltext_subclaims": [ + "The patient is a 19-month-old girl.", + "The patient had no known immunocompromise.", + "She had persistent unilateral neck lumps two weeks after lacerating her chin.", + "The laceration and swelling had healed uneventfully without specific therapy.", + "An ultrasound revealed several mild to moderately enlarged left submandibular and upper cervical lymph nodes.", + "The ultrasound findings were in keeping with inflammation.", + "Examination revealed two prominent lymph nodes on the left side of her neck.", + "An 18 mm lymph node was located in the submandibular area.", + "Another node was 22 mm towards the tail of her parotid.", + "Both nodes were fluctuant with erythema of the overlying and surrounding skin.", + "There were no fistulae present.", + "Incision and drainage with curettage was performed under general anaesthesia.", + "Copious purulent discharge was drained.", + "The discharge was sent for histological review and culture.", + "A full blood count performed was within normal limits.", + "C-reactive protein was not elevated.", + "A ten-day course of Clarithromycin 150 mg twice daily was taken post-operatively.", + "The wound healed without complication.", + "No further therapy was required." + ], + "summary": "A 19-month-old girl presented with persistent unilateral neck lumps which developed following a facial laceration. Both lumps were fluctuant with overlying erythema and no fistulae present. Incision and drainage with curettage was performed. The operative sample of purulent fluid revealed pleomorphic bacilli on Ziehl-Neelsen staining. The isolate cultured was referred for further genotypic identification via 16S rRNA gene sequencing, identifying the organism as M. stomatepiae.", + "summary_subclaims": [ + "The patient is a 19-month-old girl.", + "The patient had persistent unilateral neck lumps.", + "The neck lumps developed following a facial laceration.", + "Both lumps were fluctuant.", + "There was overlying erythema.", + "No fistulae were present.", + "Incision and drainage with curettage was performed.", + "The operative sample of purulent fluid revealed pleomorphic bacilli on Ziehl-Neelsen staining.", + "The isolate cultured was referred for further genotypic identification via 16S rRNA gene sequencing.", + "The organism was identified as M. stomatepiae." + ] + }, + { + "id": "multiclinsum_test_839_en.txt", + "fulltext": "A 45 year-old male patient presented to the outpatient unit of Internal Medicine Department in September 2019 with complaints of fever, abdominal pain (right flank), and burning micturition for 3 days. He was otherwise well in the past and none of his family members had similar illness. On physical examination, he had normal temperature, blood pressure, pulse rate, and respiratory rate. On systemic examination, he had tenderness at his right renal angle. Respiratory, cardiovascular, and neurological examinations were unremarkable. There were no rash, lymphadenopathy or hepatosplenomegaly.\nOn urine investigation, 1–2 pus cells were seen per high power field (hpf) but no red blood cells (RBC). Total white cell count (TC) including differential counts (DC), hemoglobin (Hb), platelet count, and erythrocyte sedimentation rate (ESR) were within normal limits. His blood creatinine level was 0.9 mg/dL, urea was 33 mg/dL, sodium 142 mmol/L and potassium 4.8 mmol/L. Urine and blood culture was ordered. Ultrasonography (US) of his abdomen-pelvis showed mild fatty changes in liver, right renal concretions, and prostatomegaly (approx. 26.59 g). The patient was sent home on oral cefixime 400 mg twice daily, oral diclofenac 75 mg thrice daily, and hyoscine tablet 20 mg thrice daily.\nOn Day 4, the patient returned to the outpatient unit with persistent symptoms. He was then admitted to the medical ward with intravenous (IV) ceftriaxone 1 g twice daily, Injection tramadol for pain, and intravenous fluids. Urine and blood culture reports showed no growth of pathogens. Routine laboratory investigations were repeated. Urine showed plenty pus cells but no RBCs, sugar and albumin. Serum creatinine level increased to 1.5 mg/dL whereas blood urea (30 mg/dL), sodium (135 mmol/L), and potassium (3.8 mmol/L) levels decreased. Liver panel (transaminases, total and direct bilirubin, alkaline phosphate, serum lipase, serum amylase) was normal. .\nThe patient continued to be symptomatic on Day 5 of illness despite IV medication. Routine urine and blood investigations came out unremarkable except for a sudden decrease in platelet count (190,00 on Day 4 to 115,000 on Day 5) and serum creatinine level (1.5 on Day 4 to 1.3 on Day 5). Follow-up US abdomen-pelvis showed globular right kidney with probe tenderness, suggestive of acute pyelonephritis. Antibiotics were then upgraded to IV meropenem and IV teicoplanin.\nA plain computer tomography scan of the patient’s kidneys-ureters-bladder (CT-KUB) showed right perirenal haziness and fatty strandings; thickened right lateral conal fascia with minimal surrounding haziness but no evidence of hydroureteronephrosis; tiny renal concretions, splenunculus, and plate atelectasis in the posterobasal segment of right lower lobe of right kidney; and mild degenerative changes in the visualized spine. These findings complemented the US diagnosis of acute pyelonephritis. .\nOn Day 7 of illness, the patient was still complaining right flank pain along with fever. He suddenly became tachypneic with respiratory rate of 24/min. An urgent US chest was performed which showed minimal bilateral pleural effusion. Routine laboratory investigations came out unremarkable except for decreasing creatinine level (1.2 mg/dL). Then, a possibility of serositis was suspected.\nKathmandu city was hit by dengue epidemic at the time of the patient’s hospital admission. Therefore, a possibility of tropical fever in this patient was thought of too. His blood samples were sent for the investigation for dengue virus, scrub typhus, leptospirosis, leishmaniasis (kala-azar), and malaria (optimal test). All tests came out negative except for scrub typhus –IgM antibodies positive on rapid diagnostic test. Immediately, doxycycline (100 mg IV twice daily) was added to the patient’s medication list (Day 7 of illness).\nThe patient’s clinical features and lab results did not change remarkably for 36 h of initiating doxycycline. However, over the next 48 h (Day 10 onwards), the patient showed clinical improvement. His fever and abdominal pain decreased significantly. On Day 12 of illness (9th day of admission, 7th day of IV meropenem, 5th day of IV doxycycline), the patient had a feeling of well-being, so he was sent home with oral doxycycline for 10 additional days and oral levofloxacin for 7 days.\nWhen the patient visited hospital after 6 days of discharge (Day 17), he was found apparently asymptomatic; all blood and urine investigations came out normal; and his follow-up ultrasonography findings (chest-abdomen-pelvis) were non-significant.", + "fulltext_subclaims": [ + "The patient was a 45 year-old male.", + "He presented in September 2019.", + "He had fever, abdominal pain (right flank), and burning micturition for 3 days.", + "On physical examination, he had tenderness at his right renal angle.", + "Urine investigation showed 1–2 pus cells per high power field.", + "Urine showed no red blood cells.", + "Ultrasonography showed mild fatty changes in liver.", + "Ultrasonography showed right renal concretions.", + "Ultrasonography showed prostatomegaly (approx. 26.59 g).", + "He was sent home on oral cefixime 400 mg twice daily.", + "He was sent home on oral diclofenac 75 mg thrice daily.", + "He was sent home on hyoscine tablet 20 mg thrice daily.", + "On Day 4, the patient returned with persistent symptoms.", + "He was admitted to the medical ward.", + "He received intravenous ceftriaxone 1 g twice daily.", + "Urine and blood culture showed no growth of pathogens.", + "Serum creatinine level increased to 1.5 mg/dL.", + "Follow-up ultrasonography showed globular right kidney with probe tenderness, suggestive of acute pyelonephritis.", + "Antibiotics were upgraded to IV meropenem and IV teicoplanin.", + "CT-KUB showed right perirenal haziness and fatty strandings.", + "CT-KUB showed thickened right lateral conal fascia with minimal surrounding haziness.", + "CT-KUB showed no evidence of hydroureteronephrosis.", + "CT-KUB showed tiny renal concretions.", + "CT-KUB showed mild degenerative changes in the visualized spine.", + "On Day 7, the patient was still complaining of right flank pain and fever.", + "An urgent US chest showed minimal bilateral pleural effusion.", + "Kathmandu city was hit by a dengue epidemic at the time of the patient’s hospital admission.", + "A possibility of tropical fever was thought of.", + "Scrub typhus –IgM antibodies were positive on rapid diagnostic test.", + "Doxycycline (100 mg IV twice daily) was added to the patient’s medication list.", + "The patient’s clinical features and lab results did not change remarkably for 36 h of initiating doxycycline.", + "Over the next 48 h, the patient showed clinical improvement.", + "On Day 12 of illness, the patient had a feeling of well-being.", + "He was sent home with oral doxycycline for 10 additional days.", + "He was sent home with oral levofloxacin for 7 days.", + "When the patient visited hospital after 6 days of discharge, he was found apparently asymptomatic.", + "All blood and urine investigations came out normal.", + "Follow-up ultrasonography findings were non-significant." + ], + "summary": "A 45-year old male presenting to the outpatient unit with fever, right flank pain, and burning micturition for three days was initially treated for UTI. However, he returned to the hospital on the fourth day of illness with persistent symptoms. He was hospitalized, with intravenous (IV) ceftriaxone. Computerized tomography scan of his abdomen-pelvis showed features of acute pyelonephritis, so his antibiotics were upgraded to meropenem and teicoplanin. Despite this, the patient's condition deteriorated. Laboratory investigations showed multisystem involvement: decreasing platelets, raised creatinine, and deranged liver panel. As Kathmandu was hit by dengue epidemic during the patient's hospitalization, on the seventh day of his illness, blood samples were sent for tropical fever investigation. All tests came out negative except for scrub typhus-IgM antibodies positive on rapid diagnostic test. The patient's symptoms subsided after 48 h of starting doxycycline and he became fully asymptomatic four days later. Fever did not recur even after discontinuing other IV antibiotics, favoring scrub typhus disease rather than systemic bacterial sepsis.", + "summary_subclaims": [ + "The patient is a 45-year-old male.", + "He presented with fever, right flank pain, and burning micturition for three days.", + "He was initially treated for UTI.", + "He returned to the hospital on the fourth day of illness.", + "He was hospitalized.", + "He received intravenous ceftriaxone.", + "Computerized tomography scan showed features of acute pyelonephritis.", + "His antibiotics were upgraded to meropenem and teicoplanin.", + "The patient's condition deteriorated.", + "Laboratory investigations showed multisystem involvement.", + "Kathmandu was hit by a dengue epidemic during the patient's hospitalization.", + "Blood samples were sent for tropical fever investigation on the seventh day of illness.", + "Scrub typhus-IgM antibodies were positive on rapid diagnostic test.", + "The patient's symptoms subsided after 48 h of starting doxycycline.", + "He became fully asymptomatic four days after starting doxycycline.", + "Fever did not recur after discontinuing other IV antibiotics." + ] + }, + { + "id": "multiclinsum_test_450_en.txt", + "fulltext": "A 78-year-old Japanese man with ischemic heart disease, chronic heart failure, and type 2 diabetes was presented with a complaint of fever for 2 days. He had reportedly completed a 12-day course of intravenous ceftriaxone treatment for E. coli pyelonephritis without bacteremia, 8 days earlier. He had persistent fever despite having received empirical oral levofloxacin for the last 2 days and was admitted for further investigations and management. Physical examination revealed a body temperature of 38.9 °C, respiratory rate of 24 breaths per minute, heart rate of 116 beats per minute, and tenderness of the prostate gland. Laboratory findings showed a white blood cell count of 10,810/μL (neutrophils, 90.1%); C-reactive protein, 316 mg/L; hemoglobin A1c, 9.5%; urinary leukocytes, 0–1/HPF; and no evidence of urinary nitrites.\nA full-body enhanced computed tomography scan showed no evidence of infectious foci, including abscesses. However, blood culture results revealed the presence of E. coli bacteremia. Therefore, we initiated intravenous cefmetazole, considering suspected bacteremic prostatitis. However, transthoracic echocardiography was performed as part of the workup for recurrent fever, which revealed moderate mitral regurgitation and a high echoic structure (measuring 13 mm × 5 mm diameter) on the posterior mitral leaflet . Since the structure was not detected in the previous transthoracic echocardiography performed 3-months earlier, we also conducted transesophageal echocardiography. It revealed a high and low echoic heterogenous immobilized structure (measuring 10.2 mm × 11.7 mm in diameter) attached to the annulus of the mitral valve from P2 to P3 and showed hypermobile vegetation (measuring 18 mm × 4.2 mm in diameter) attached continuously to the immobilized structure . With bacteremia evidence and echocardiography findings, we diagnosed the patient with infective endocarditis associated with a suspicious calcified amorphous tumor. Antibiotic treatment was modified to ceftriaxone and gentamicin following the diagnosis because E. coli was not a multidrug-resistant strain. E. coli was detected on blood culture samples taken on day-1 and day-5 of hospitalization, confirming persistent bacteremia. On day-6 of hospitalization, the patient developed altered mental status. A head magnetic resonance imaging scan was performed, which revealed bilateral acute multiple cerebral infarctions . Since no acute hemorrhagic transformation after the stroke was identified by the follow-up computed tomography, we performed removal of the vegetation and mitral valvuloplasty on day-7 of hospitalization. Cardiopulmonary bypass was established with the initial intravenous administration of heparin (300 U/kg) and maintained the activated clotting time above 400 s. Intravenous heparin was switched to oral warfarin postoperatively. There was no intraoperative or postoperative cerebral hemorrhage. Histopathological examination of the specimen showed calcified deposits and inflammatory granulation tissue infiltrated by neutrophils . The patient experienced renal insufficiency 21 days after admission, and the treatment was changed from ceftriaxone with gentamicin to ceftriaxone with ciprofloxacin. Antibiotic treatment was administered for 6 weeks from the day of the first negative blood culture result (7 days after admission). The patient recovered fully from the infection and was transferred to a rehabilitation hospital 77 days after admission.", + "fulltext_subclaims": [ + "The patient is a 78-year-old Japanese man.", + "The patient has ischemic heart disease.", + "The patient has chronic heart failure.", + "The patient has type 2 diabetes.", + "The patient had a 12-day course of intravenous ceftriaxone for E. coli pyelonephritis.", + "The patient had no bacteremia after the ceftriaxone treatment.", + "The patient had persistent fever despite receiving oral levofloxacin for 2 days.", + "The patient was admitted for further investigations.", + "The patient's body temperature was 38.9 °C.", + "The patient's heart rate was 116 beats per minute.", + "The patient had tenderness of the prostate gland.", + "The white blood cell count was 10,810/μL.", + "The neutrophil percentage was 90.1%.", + "The C-reactive protein level was 316 mg/L.", + "The hemoglobin A1c was 9.5%.", + "Urinary leukocytes were 0–1/HPF.", + "There was no evidence of urinary nitrites.", + "A full-body enhanced computed tomography scan showed no evidence of infectious foci.", + "Blood culture results revealed the presence of E. coli bacteremia.", + "Intravenous cefmetazole was initiated.", + "Transthoracic echocardiography revealed moderate mitral regurgitation.", + "A high echoic structure measuring 13 mm × 5 mm was found on the posterior mitral leaflet.", + "The structure was not detected in the previous transthoracic echocardiography performed 3 months earlier.", + "Transesophageal echocardiography revealed a high and low echoic heterogenous immobilized structure attached to the annulus of the mitral valve from P2 to P3.", + "Transesophageal echocardiography showed hypermobile vegetation measuring 18 mm × 4.2 mm.", + "The vegetation was attached continuously to the immobilized structure.", + "The patient was diagnosed with infective endocarditis.", + "The diagnosis was associated with a suspicious calcified amorphous tumor.", + "Antibiotic treatment was modified to ceftriaxone and gentamicin.", + "E. coli was not a multidrug-resistant strain.", + "E. coli was detected on blood culture samples taken on day-1 and day-5 of hospitalization.", + "The patient developed altered mental status on day-6 of hospitalization.", + "A head magnetic resonance imaging scan revealed bilateral acute multiple cerebral infarctions.", + "No acute hemorrhagic transformation was identified by follow-up computed tomography.", + "Vegetation removal and mitral valvuloplasty were performed on day-7 of hospitalization.", + "Cardiopulmonary bypass was established with heparin.", + "Intravenous heparin was switched to oral warfarin postoperatively.", + "There was no intraoperative or postoperative cerebral hemorrhage.", + "Histopathological examination showed calcified deposits.", + "Inflammatory granulation tissue infiltrated by neutrophils was found.", + "The patient experienced renal insufficiency 21 days after admission.", + "Antibiotic treatment was changed to ceftriaxone with ciprofloxacin.", + "Antibiotic treatment was administered for 6 weeks.", + "The patient recovered fully from the infection.", + "The patient was transferred to a rehabilitation hospital 77 days after admission." + ], + "summary": "We present a case of infective endocarditis caused by E. coli in a 78-year-old Japanese man with type 2 diabetes, involving persistent bacteremia and vegetation on the mitral valve (measuring 18 × 4.2 mm in diameter). He presented with recurrent fever after antimicrobial treatment for pyelonephritis. He received antibiotic therapy for 6 weeks and required surgical removal of a calcified amorphous tumor and vegetation with mitral valvuloplasty 7 days after admission. Despite an episode of multiple cerebral infarctions, he recovered fully from the infection.", + "summary_subclaims": [ + "The patient was a 78-year-old Japanese man.", + "The patient had type 2 diabetes.", + "The infective endocarditis was caused by E. coli.", + "The patient had persistent bacteremia.", + "The vegetation was on the mitral valve.", + "The vegetation measured 18 × 4.2 mm in diameter.", + "The patient presented with recurrent fever after antimicrobial treatment for pyelonephritis.", + "He received antibiotic therapy for 6 weeks.", + "He required surgical removal of a calcified amorphous tumor and vegetation.", + "He underwent mitral valvuloplasty 7 days after admission.", + "He had an episode of multiple cerebral infarctions.", + "He recovered fully from the infection." + ] + }, + { + "id": "multiclinsum_test_1261_en.txt", + "fulltext": "A 71-year-old man was scheduled to undergo total hip replacement surgery under general anesthesia to fix malunion of the right hip joint. Two months before the scheduled procedure, he had undergone left bipolar hip arthroplasty and right acetabular fracture fixation due to bilateral acetabular cartridge fractures. After the fractures, the patient had been prescribed oral polystyrene sulfonate calcium because of hyperkalemia. He was diagnosed to have PNH at the age of 60, and the oral administration of prednisolone was initiated. The therapy with eculizumab was not initiated.\nThe preoperative blood examination showed pancytopenia [white blood cells, 2.100/μl; hemoglobin (Hb), 12.7 g/dl; and platelets, 100 × 103/μl]. We suspected a hemolytic reaction due to the presence of a slightly increased aspartate aminotransferase, although bilirubin and lactase dehydrogenase level were within the normal limits. The hyperkalemia improved with the polystyrene sulfonate calcium. The irregular antibody screening was positive. Therefore, 6 units of packed RBCs and a blood salvage device (electa™; Sorin Group Italia, Italy) were prepared. No other abnormal results in the cardiac, liver, or renal functions were observed.\nFigure a depicts the intraoperative progress course. The Hb and potassium (K+) levels after the anesthesia induction were 11.5 g/dL and 4.6 mmol/L, respectively. An hour after the operation started, the same levels became 9.6 g/dL and 5.4 mmol/L, respectively, due to unexpected bleeding and presumably intravascular hemolysis. We initiated blood salvage procedures and started transfusion of 2 units of prepared packed RBCs using a potassium adsorption filter. After that, 190 ml of the first salvaged autologous RBCs were re-infused. Blood examination results to check K+ concentration levels in the transfer bag showed a high level of 6.2 mmol/L in the salvaged RBCs. Because the patient’s Hb became 7.6 g/dL due to continuous bleeding, we transfused two more units of packed RBCs and re-infused 90 ml of the second salvaged autologous RBCs using a potassium adsorption filter. The value of K+ in the transfer bag of the second salvaged autologous RBCs batch was also high at 6.0 mmol/L. The patient’s Hb level recovered to 10.5 g/dL after the RBC transfusion. However, the hyperkalemia progressed to 6.8 mmol/L of K+, and we administered 850 mg of calcium gluconate and initiated glucose-insulin therapy. Although the operation was close to being finished, we transfused two more units of packed RBCs anticipating the possibility of intravascular hemolysis after the operation. The surgery was performed without complications. The value of K+ at the end of the operation was 4.9 mmol/L. The amount of bleeding during the operation was 1900 ml, and the infusion volume during the operation was 2400 ml of crystalloids, 6 units of packed RBCs, and 280 ml of salvaged autologous RBCs. The duration of surgery and anesthesia was 140 and 215 min, respectively. Postoperatively, the patient was transferred to the intensive care unit (ICU).\nFigure b indicates the patient’s progress after the operation. Glucose-insulin therapy was continued until the postoperative day (POD) 1. The patient left the ICU and restarted the oral intake of polystyrene sulfonate calcium at POD 3 because the K+ increased again. At POD 18, the patient was transferred to another hospital for rehabilitation.", + "fulltext_subclaims": [ + "The patient was scheduled to undergo total hip replacement surgery under general anesthesia.", + "The surgery was to fix malunion of the right hip joint.", + "Two months before the scheduled procedure, the patient had undergone left bipolar hip arthroplasty.", + "Two months before the scheduled procedure, the patient had undergone right acetabular fracture fixation.", + "The patient had been prescribed oral polystyrene sulfonate calcium because of hyperkalemia.", + "The patient was diagnosed to have PNH at the age of 60.", + "The therapy with eculizumab was not initiated.", + "The preoperative blood examination showed pancytopenia.", + "The white blood cell count was 2.100/μl.", + "The hemoglobin level was 12.7 g/dl.", + "The platelet count was 100 × 103/μl.", + "The irregular antibody screening was positive.", + "6 units of packed RBCs and a blood salvage device were prepared.", + "The Hb and potassium levels after anesthesia induction were 11.5 g/dL and 4.6 mmol/L, respectively.", + "An hour after the operation started, the Hb and potassium levels became 9.6 g/dL and 5.4 mmol/L, respectively.", + "We initiated blood salvage procedures.", + "We started transfusion of 2 units of prepared packed RBCs using a potassium adsorption filter.", + "190 ml of the first salvaged autologous RBCs were re-infused.", + "The K+ concentration in the transfer bag of the first salvaged RBCs was 6.2 mmol/L.", + "The patient’s Hb became 7.6 g/dL due to continuous bleeding.", + "We transfused two more units of packed RBCs.", + "90 ml of the second salvaged autologous RBCs were re-infused using a potassium adsorption filter.", + "The K+ concentration in the transfer bag of the second salvaged RBCs was 6.0 mmol/L.", + "The patient’s Hb level recovered to 10.5 g/dL after the RBC transfusion.", + "The hyperkalemia progressed to 6.8 mmol/L of K+.", + "We administered 850 mg of calcium gluconate.", + "We initiated glucose-insulin therapy.", + "We transfused two more units of packed RBCs anticipating the possibility of intravascular hemolysis after the operation.", + "The surgery was performed without complications.", + "The value of K+ at the end of the operation was 4.9 mmol/L.", + "The amount of bleeding during the operation was 1900 ml.", + "The infusion volume during the operation was 2400 ml of crystalloids.", + "The infusion volume during the operation included 6 units of packed RBCs.", + "The infusion volume during the operation included 280 ml of salvaged autologous RBCs.", + "The duration of surgery was 140 minutes.", + "The duration of anesthesia was 215 minutes.", + "The patient was transferred to the ICU postoperatively.", + "Glucose-insulin therapy was continued until the postoperative day 1.", + "The patient left the ICU and restarted the oral intake of polystyrene sulfonate calcium at postoperative day 3.", + "The patient was transferred to another hospital for rehabilitation at postoperative day 18." + ], + "summary": "A 71-year-old man underwent total hip replacement surgery. An autologous blood salvage device was put in place due to the large bleeding volume and the existence of an irregular antibody. The potassium concentration in the transfer bag of salvaged RBCs after the wash process was high at 6.2 mmol/L, although the washing generally removes > 90% of the potassium from the blood. This may have been caused by continued hemolysis even after the wash process. Once activated, the complement in patients with PNH forms the MAC on the RBCs, and the hemolytic reaction may not be stopped even with RBC washing.", + "summary_subclaims": [ + "The patient is a 71-year-old man.", + "The patient underwent total hip replacement surgery.", + "An autologous blood salvage device was put in place.", + "The autologous blood salvage device was used due to the large bleeding volume.", + "The autologous blood salvage device was used due to the existence of an irregular antibody.", + "The potassium concentration in the transfer bag of salvaged RBCs after the wash process was 6.2 mmol/L.", + "The washing generally removes > 90% of the potassium from the blood.", + "The high potassium concentration may have been caused by continued hemolysis even after the wash process.", + "Once activated, the complement in patients with PNH forms the MAC on the RBCs.", + "The hemolytic reaction may not be stopped even with RBC washing." + ] + }, + { + "id": "multiclinsum_test_755_en.txt", + "fulltext": "A 60-year-old Japanese woman presented with numbness in both lower extremities. This symptom appeared four months prior to admission, and she experienced giddiness two months before. However, she had ignored these symptoms. Her medical history revealed that she had undergone an oophorectomy, and she had a uterine sarcoma at the age of 36 and mastitis at the age of 45. Her consciousness was clear but she had anaemic conjunctivae. Physical examination revealed that she was a well-nourished female with normal vital signs. She had no chest pain. Her liver and spleen were not palpable. Although she experienced numbness in both her lower limbs, the neurological findings were normal, and neither extremity was cold.\nThe patient had a white-blood-cell count of 2.74 × 103/μl with 37% neutrophils, 62% lymphocytes and 1% monocytes. Her haemoglobin level was 7.8 g/dl and her platelet count was 1787 × 103/μl. Examination of bone-marrow aspirate revealed normal cellular marrow, megakaryocytic hyperplasia and erythroid dysplasia. Her karyogram was normal.\nAbdominal ultrasonography revealed in the aorta a moveable mass with a diameter of 1.5 cm. The interior of the mass had no blood supply. A computed tomographic scan of her abdomen revealed a circular thrombus in the descending aorta at the level of the diaphragm . Arteriosclerosis was not recognized at that point.\nWe diagnosed this case of thrombocytosis and anemia as myelodysplastic syndrome and/or myeloproliferative disorder-unclassifiable (MDS/MPD-U), and the aortic thrombus was thought to be associated with myeloproliferative thrombocytosis.\nFor myeloproliferative thrombocytosis, she was treated with 500 mg of hydroxyurea from the seventh day of her hospital stay. However, she was administered 1000 mg of hydroxyurea on the 16th day because her platelet count increased to 2074 × 103/μl. In addition, she was administered 50 mg of ranimustine on the 18th day. The platelet count decreased to 274 × 103 /μl on the 39th day, but it increased slowly thereafter. After administration of 1000 mg of hydroxyurea, her platelet count stabilized at approximately 1000 × 103/μl. She was administered transfusions for anemia.\nTiclopidine was administered to prevent the development of a thrombosis on the seventh hospital day, which was the same day treatment for myeloproliferative thrombocytosis was initiated. Aspirin (100 mg) was administered when an aortic thrombus was identified by computed tomographic scan on the 10th day of her hospital stay. The numbness in both of her lower extremities disappeared within two days. Also, the aortic thrombus was not observed in the computed tomographic scan on the 17th day of her hospital stay. She was administered aspirin after seven days . She has been without symptoms for more than one year.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Japanese woman.", + "She presented with numbness in both lower extremities.", + "This symptom appeared four months prior to admission.", + "She experienced giddiness two months before admission.", + "She had ignored these symptoms.", + "Her medical history included an oophorectomy.", + "She had a uterine sarcoma at the age of 36.", + "She had mastitis at the age of 45.", + "Her consciousness was clear.", + "She had anaemic conjunctivae.", + "She was a well-nourished female.", + "Her vital signs were normal.", + "She had no chest pain.", + "Her liver and spleen were not palpable.", + "She had numbness in both her lower limbs.", + "The neurological findings were normal.", + "Neither extremity was cold.", + "Her white-blood-cell count was 2.74 × 103/μl.", + "Her haemoglobin level was 7.8 g/dl.", + "Her platelet count was 1787 × 103/μl.", + "Examination of bone-marrow aspirate revealed normal cellular marrow.", + "Examination of bone-marrow aspirate revealed megakaryocytic hyperplasia.", + "Examination of bone-marrow aspirate revealed erythroid dysplasia.", + "Her karyogram was normal.", + "Abdominal ultrasonography revealed a moveable mass in the aorta with a diameter of 1.5 cm.", + "The interior of the mass had no blood supply.", + "A computed tomographic scan of her abdomen revealed a circular thrombus in the descending aorta at the level of the diaphragm.", + "Arteriosclerosis was not recognized at that point.", + "The diagnosis was myelodysplastic syndrome and/or myeloproliferative disorder-unclassifiable.", + "The aortic thrombus was thought to be associated with myeloproliferative thrombocytosis.", + "She was treated with 500 mg of hydroxyurea from the seventh day of her hospital stay.", + "She was administered 1000 mg of hydroxyurea on the 16th day because her platelet count increased to 2074 × 103/μl.", + "She was administered 50 mg of ranimustine on the 18th day.", + "Her platelet count decreased to 274 × 103/μl on the 39th day.", + "Her platelet count increased slowly thereafter.", + "After administration of 1000 mg of hydroxyurea, her platelet count stabilized at approximately 1000 × 103/μl.", + "She was administered transfusions for anemia.", + "Ticlopidine was administered to prevent the development of a thrombosis on the seventh hospital day.", + "Aspirin (100 mg) was administered when an aortic thrombus was identified by computed tomographic scan on the 10th day of her hospital stay.", + "The numbness in both of her lower extremities disappeared within two days.", + "The aortic thrombus was not observed in the computed tomographic scan on the 17th day of her hospital stay.", + "She was administered aspirin after seven days.", + "She has been without symptoms for more than one year." + ], + "summary": "A 60-year-old Japanese woman presented with numbness of both lower extremities. Her platelet count was 1787 x 103/mul. Through bone marrow examination, we diagnosed her condition as myelodysplastic and/or myeloproliferative disorder-unclassifiable. Abdominal ultrasonography and computed tomographic scan revealed aortic thrombosis. Her platelet count was controlled with hydroxyurea and ranimustine. Aspirin and ticlopidine improved the numbness in both lower limbs on the second day. Aortic thrombosis was not observed in a computed tomographic scan on the seventh day.", + "summary_subclaims": [ + "The patient is a 60-year-old Japanese woman.", + "She presented with numbness of both lower extremities.", + "Her platelet count was 1787 x 103/mul.", + "Bone marrow examination was performed.", + "The diagnosis was myelodysplastic and/or myeloproliferative disorder-unclassifiable.", + "Abdominal ultrasonography was performed.", + "Computed tomographic scan revealed aortic thrombosis.", + "Her platelet count was controlled with hydroxyurea and ranimustine.", + "Aspirin and ticlopidine improved the numbness in both lower limbs on the second day.", + "Aortic thrombosis was not observed in a computed tomographic scan on the seventh day." + ] + }, + { + "id": "multiclinsum_test_1753_en.txt", + "fulltext": "A 5-year-old girl was presented to our institution because of failure to thrive. She was the fifth child of unrelated parents originating from the same village in the south of Lebanon. She was born vaginally at term to a 33-year-old mother; her birth weight was 2,200 grams. The course of pregnancy was normal and the mother denied any medication use, smoking, or alcohol intake. The girl’s perinatal history was significant for neonatal jaundice requiring phototherapy. The family history was unremarkable except for mental retardation in a maternal uncle and a congenital heart defect in an older brother.\nIn early infancy, the girl had feeding difficulties and failed to thrive. She also had a history of recurrent respiratory infections and eczematous skin changes. In addition, since birth she had had a musty urine odor that had never been reported in her family. Urine analyses were repeatedly normal.\nAt consultation, developmental evaluation revealed a hyperactive child with significant speech delay. Her vocabulary consisted of 10–15 words. She used few two-word sentences. Otherwise, the gross and fine motor abilities were adequate for her age. She made good eye contact and could understand and carry out simple verbal instructions, but she had a short attention span and impulsive behavior.\nUpon examination, her height was reported at 84 cm, her weight was 10 kg, and her head circumference was 44 cm, all below the third percentile according to US Centers for Disease Control growth charts.\nShe had fair, dry skin and sparse, fine blond hair. Her face was elongated with a high sloping forehead. She had sparse lateral eyebrows, long eyelashes, wide-set eyes (telecanthus) with hypertelorism, low-set ears, a broad nasal bridge with a prominent tip, micrognathia, a thin upper lip, a high-arched palate, dental caries, a sacral dimple, and eczematous skin changes on the extremities, mainly on the flexural areas ( and ).\nWhen she smiled, her facial skin wrinkled and she looked like a prematurely aged girl . The remainder of the physical examination was normal.\nLaboratory workup yielded normal results for the following tests: complete blood count, serum blood urea nitrogen, creatinine, sodium, potassium, chloride, total serum protein, liver function, lipid profile, thyroid hormone, urine organic acids, plasma acylcarnitine profile and free carnitine level, plasma amino acids, serum lactate and pyruvate levels, plasma zinc, plasma immunoglobulins including normal immunoglobulin E levels, urinalysis, urine cultures, stool studies, insulin-like growth factor 1, antiendomyseal antibodies, sweat chloride, and 46, XX karyotype.\nOther tests included MRI examination of the brain, X-rays of the spine, a voiding cystourethrogram, and an upper gastrointestinal series; all were normal. An echocardiography revealed a trace mitral regurgitation. Bone age was 2-years delayed compared with the chronological age.", + "fulltext_subclaims": [ + "The patient is a 5-year-old girl.", + "She was born vaginally at term.", + "Her birth weight was 2,200 grams.", + "The mother denied any medication use, smoking, or alcohol intake.", + "The girl’s perinatal history was significant for neonatal jaundice requiring phototherapy.", + "The family history was unremarkable except for mental retardation in a maternal uncle and a congenital heart defect in an older brother.", + "In early infancy, the girl had feeding difficulties.", + "She had a history of recurrent respiratory infections.", + "She had eczematous skin changes.", + "She had a musty urine odor since birth.", + "The urine odor had never been reported in her family.", + "Urine analyses were repeatedly normal.", + "Developmental evaluation revealed a hyperactive child with significant speech delay.", + "Her vocabulary consisted of 10–15 words.", + "She used few two-word sentences.", + "The gross and fine motor abilities were adequate for her age.", + "She made good eye contact.", + "She could understand and carry out simple verbal instructions.", + "She had a short attention span.", + "She had impulsive behavior.", + "Her height was reported at 84 cm.", + "Her weight was 10 kg.", + "Her head circumference was 44 cm.", + "All measurements were below the third percentile according to US Centers for Disease Control growth charts.", + "She had fair, dry skin.", + "She had sparse, fine blond hair.", + "Her face was elongated with a high sloping forehead.", + "She had sparse lateral eyebrows.", + "She had long eyelashes.", + "She had wide-set eyes (telecanthus) with hypertelorism.", + "She had low-set ears.", + "She had a broad nasal bridge with a prominent tip.", + "She had micrognathia.", + "She had a thin upper lip.", + "She had a high-arched palate.", + "She had dental caries.", + "She had a sacral dimple.", + "She had eczematous skin changes on the extremities, mainly on the flexural areas.", + "When she smiled, her facial skin wrinkled and she looked like a prematurely aged girl.", + "The complete blood count was normal.", + "The serum blood urea nitrogen was normal.", + "The creatinine was normal.", + "The sodium was normal.", + "The potassium was normal.", + "The chloride was normal.", + "The total serum protein was normal.", + "The liver function tests were normal.", + "The lipid profile was normal.", + "The thyroid hormone levels were normal.", + "The urine organic acids were normal.", + "The plasma acylcarnitine profile and free carnitine level were normal.", + "The plasma amino acids were normal.", + "The serum lactate and pyruvate levels were normal.", + "The plasma zinc was normal.", + "The plasma immunoglobulins were normal.", + "The urinalysis was normal.", + "The urine cultures were normal.", + "The stool studies were normal.", + "The insulin-like growth factor 1 was normal.", + "The antiendomyseal antibodies were normal.", + "The sweat chloride was normal.", + "The 46, XX karyotype was normal.", + "The MRI examination of the brain was normal.", + "The X-rays of the spine were normal.", + "The voiding cystourethrogram was normal.", + "The upper gastrointestinal series was normal.", + "An echocardiography revealed a trace mitral regurgitation.", + "The bone age was 2-years delayed compared with the chronological age." + ], + "summary": "We present here the case of a Lebanese girl with Dubowitz syndrome in whom an unpleasant urine odor was persistently reported since birth.", + "summary_subclaims": [ + "We present here the case of a Lebanese girl with Dubowitz syndrome.", + "An unpleasant urine odor was persistently reported since birth." + ] + }, + { + "id": "multiclinsum_test_172_en.txt", + "fulltext": "A 68-year-old Asian man with no smoking history was diagnosed with right lower lobe lung adenocarcinoma with multiple osseous metastases but without brain metastasis in October 2014 when he presented with severe back pain. Molecular study of a tissue biopsy revealed EGFR mutation L858R, sensitive to EGFR TKIs. Treatment with gefitinib, a first-generation TKI, was initiated in November 2014. The patient tolerated therapy well and exhibited an excellent clinical response until November 2015 when he started to experience progressive worsening of lower back pain and bilateral lower extremity weakness. Imaging studies demonstrated disease progression, and thus re-biopsy of the right lower lobe lesion was performed to search for a T790M mutation, the most common molecular abnormality responsible for resistance to targeted therapy. Somewhat surprisingly, biopsy sample mutation studies again demonstrated EGFR L858R but without a T790M mutation. The patient declined systemic cytotoxic chemotherapy and palliative radiation to the lumbar spine metastasis, but continued with gefitinib.\nThe patient transferred his care to our center at the end of January 2016. Unfortunately, he continued to deteriorate clinically and developed intractable lower back pain and bilateral lower extremity weakness, but no incontinence. Repeat magnetic resonance imaging (MRI) of the spine showed metastases at multiple levels involving the thoracic, lumbar, and sacral spines without compromise of the central canal or compression of the spinal nerve roots. The patient received urgent palliative radiation of 35 Gy in 14 fractions from T7-S2 spine, demonstrating a favorable symptomatic response. The patient was subsequently hospitalized for persistent confusion, generalized fatigue, anorexia, and failure to thrive. Neurological examination revealed mental status changes, but no focal neurological deficits. MRI of the brain demonstrated extensive leptomeningeal carcinomatosis , which was believed to be the cause of his symptomatology. In view of the previous failed attempt to identify a T790M mutation via tissue biopsy, a liquid biopsy was undertaken which revealed an EGFR T790M mutation. Osimertinib 80 mg p.o. daily was initiated despite lack of solid clinical evidence for the utility of this agent in LM.\nThe patient responded rapidly, displayed substantial clinical improvement within 2 weeks of starting therapy, and became symptom-free after 3 months of treatment. Six months after initiation of osimertinib, repeat MRI of the brain revealed marked reduction of LM . Unfortunately, the patient developed hearing loss, confusion, and short-term memory loss approximately 1 year later in February 2017. Computerized tomography of the abdomen showed a few enlarged retroperitoneal lymph nodes, consistent with metastasis. MRI of the brain demonstrated progression of LM involving the cerebellar vermis, right occipital lobe as well as bilateral temporal and parietal lobes. The patient declined further systemic chemotherapy and expired after a short time interval.", + "fulltext_subclaims": [ + "The patient is a 68-year-old Asian man.", + "The patient has no smoking history.", + "The patient was diagnosed with right lower lobe lung adenocarcinoma.", + "The patient had multiple osseous metastases.", + "The patient did not have brain metastasis at diagnosis.", + "The patient presented with severe back pain.", + "Molecular study of a tissue biopsy revealed EGFR mutation L858R.", + "The EGFR L858R mutation is sensitive to EGFR TKIs.", + "Treatment with gefitinib was initiated in November 2014.", + "The patient tolerated gefitinib therapy well.", + "The patient exhibited an excellent clinical response to gefitinib.", + "In November 2015, the patient started to experience progressive worsening of lower back pain.", + "In November 2015, the patient experienced bilateral lower extremity weakness.", + "Imaging studies demonstrated disease progression.", + "A re-biopsy of the right lower lobe lesion was performed.", + "The re-biopsy was performed to search for a T790M mutation.", + "The T790M mutation is the most common molecular abnormality responsible for resistance to targeted therapy.", + "The biopsy sample mutation studies again demonstrated EGFR L858R.", + "The biopsy sample did not demonstrate a T790M mutation.", + "The patient declined systemic cytotoxic chemotherapy.", + "The patient declined palliative radiation to the lumbar spine metastasis.", + "The patient continued with gefitinib.", + "The patient transferred his care to our center at the end of January 2016.", + "The patient continued to deteriorate clinically.", + "The patient developed intractable lower back pain.", + "The patient developed bilateral lower extremity weakness.", + "The patient did not develop incontinence.", + "Repeat MRI of the spine showed metastases at multiple levels involving the thoracic, lumbar, and sacral spines.", + "The spine metastases did not compromise the central canal.", + "The spine metastases did not compress the spinal nerve roots.", + "The patient received urgent palliative radiation of 35 Gy in 14 fractions from T7-S2 spine.", + "The patient demonstrated a favorable symptomatic response to the palliative radiation.", + "The patient was hospitalized for persistent confusion.", + "The patient was hospitalized for generalized fatigue.", + "The patient was hospitalized for anorexia.", + "The patient was hospitalized for failure to thrive.", + "Neurological examination revealed mental status changes.", + "Neurological examination did not reveal focal neurological deficits.", + "MRI of the brain demonstrated extensive leptomeningeal carcinomatosis.", + "The leptomeningeal carcinomatosis was believed to be the cause of the patient's symptomatology.", + "A liquid biopsy was undertaken.", + "The liquid biopsy revealed an EGFR T790M mutation.", + "Osimertinib 80 mg p.o. daily was initiated.", + "Osimertinib was initiated despite lack of solid clinical evidence for its utility in leptomeningeal carcinomatosis.", + "The patient responded rapidly to osimertinib.", + "The patient displayed substantial clinical improvement within 2 weeks of starting osimertinib.", + "The patient became symptom-free after 3 months of osimertinib treatment.", + "Six months after initiation of osimertinib, repeat MRI of the brain revealed marked reduction of leptomeningeal carcinomatosis.", + "The patient developed hearing loss approximately 1 year later.", + "The patient developed confusion approximately 1 year later.", + "The patient developed short-term memory loss approximately 1 year later.", + "Computerized tomography of the abdomen showed a few enlarged retroperitoneal lymph nodes.", + "The enlarged retroperitoneal lymph nodes were consistent with metastasis.", + "MRI of the brain demonstrated progression of leptomeningeal carcinomatosis.", + "The leptomeningeal carcinomatosis involved the cerebellar vermis.", + "The leptomeningeal carcinomatosis involved the right occipital lobe.", + "The leptomeningeal carcinomatosis involved the bilateral temporal lobes.", + "The leptomeningeal carcinomatosis involved the bilateral parietal lobes.", + "The patient declined further systemic chemotherapy.", + "The patient expired after a short time interval." + ], + "summary": "We report the case of a 68-year-old Asian man with metastatic lung adenocarcinoma harboring an EGFR L858R mutation, which was initially treated with gefitinib. He developed disease progression 1 year later. Re-biopsy of the right lower lobe primary lesion revealed only an EGFR L858R mutation in the absence of a T790M mutation. The patient also experienced persistent confusion and generalized fatigue, and magnetic resonance imaging (MRI) of the brain demonstrated extensive LM. At this time, a liquid biopsy revealed an EGFR T790M mutation. Following initiation of treatment with osimertinib, the patient exhibited a rapid response with MRI of the brain showing substantial improvement of the LM after 6 months. Unfortunately, the LM recurred after 1 year at which time the patient declined further systemic chemotherapy.", + "summary_subclaims": [ + "The patient is a 68-year-old Asian man.", + "The patient has metastatic lung adenocarcinoma.", + "The tumor harbors an EGFR L858R mutation.", + "The patient was initially treated with gefitinib.", + "Disease progression occurred 1 year after starting gefitinib.", + "Re-biopsy of the right lower lobe primary lesion revealed only an EGFR L858R mutation.", + "The re-biopsy did not detect a T790M mutation.", + "The patient experienced persistent confusion.", + "The patient experienced generalized fatigue.", + "MRI of the brain demonstrated extensive leptomeningeal metastases.", + "A liquid biopsy revealed an EGFR T790M mutation.", + "The patient was treated with osimertinib.", + "MRI of the brain showed substantial improvement of the leptomeningeal metastases after 6 months.", + "The leptomeningeal metastases recurred after 1 year.", + "The patient declined further systemic chemotherapy." + ] + }, + { + "id": "multiclinsum_test_2283_en.txt", + "fulltext": "A 39-year-old Indonesian male presented to the digestive clinic department with a 7-day history of jaundice. Jaundice was associated with epigastric discomfort, nausea, loss of appetite, and skin itch. He had a history of benign brain tumors and underwent craniotomies three times, at ages 16, 17, and 24. The type of brain tumor and specific procedure are not well known by the patient. Six months before the onset of jaundice, he was diagnosed with diabetes mellitus and began taking oral diabetic medications. The family history was remarkable; it was revealed that two of the four siblings of the patient have similar conditions. Both of his siblings underwent brain tumor resection, total pancreatectomy, and nephrectomy for Von Hippel-Lindau (VHL)-associated tumors. Vital signs were within normal range, and physical examination revealed jaundice on the skin and sclera, epigastric pain, and a palpable lump in the epigastric region and both of his flanks.\nLaboratory workup revealed elevated bilirubin levels, with serum total bilirubin of 6.54 mg/dL and conjugated bilirubin of 5.24 mg/dL. The contrast-enhanced MRI of abdomen with MRCP revealed dilatation of biliary tree consisting of right and left intrahepatic bile duct, common hepatic duct, cystic duct, and common bile duct without the presence of stone with suspicion partial obstruction by multiple cysts in the pancreas with diameters ranging from ±0.5–5 cm with ring enhancement, multiple cyst lesion with ring enhancement in both kidney and gallbladder hydrops with cholecystitis . PET/CT scan showed an ametabolic hypodense lesion in the left side of the cerebellum, multiple hypodense nodules or cysts with multiple calcifications covering the entire pancreas, a solid hypermetabolic nodule in the left adrenal gland with suspicious pheochromocytomas, and an ametabolic hypodense multiple lesion in both kidneys. All radiologic findings correspond to von-Hippel-Lindau disease .\nTotal pancreatoduodenectomy was decided after considering the lesion in the entire pancreas, which contains solid and cystic nodules, also the presence of endocrine pancreatic insufficiency. Following an evaluation of his fundamental condition and the exclusion of any contraindications, surgery was scheduled.\nIntraoperatively, it was discovered that the cysts were seen in the entire pancreas with dilatation of biliary tree . Therefore, total pancreaticoduodenectomy was performed and followed by reconstruction with end-to-side choledochojejunostomy, side-to-side gastrojejunostomy, and subhepatic drainage was placed .\nThe histopathological findings showed multiple serous cystic neoplasms with calcification. Immunohistochemically, the report further confirmed multicystic pancreatic hamartoma with neuroendocrine cell hyperplasia and the lesion still showed an islet of Langerhans structure. Diagnosis is supported by diffuse positive in Cytokeratin 19 (CK19) and CK7 in cystic lesions, negative CEA, positive synaptophysin and chromogranin in nodular lesions, and positive Ki67% (0.2 %) which exclude adenocarcinoma or neuroendocrine tumor findings .\nThe management of the patient is optimally performed by an interprofessional healthcare team. Glycemic control after total pancreatectomy is handled and monitored by an endocrinologist. The insulin regimen prescribed for the patient was as follows: 10 IU of basal insulin taken in the evening, 8 IU and 10 IU of rapid-acting insulin given bolus during breakfast and dinner, respectively. The treatment for exocrine insufficiency was enzyme-substitution drug, which contains amylase, protease, deoxycholic acid, dimethylpolysiloxane, vitamin B1, vitamin B2, vitamin B6, niacinamide, and calcium pantothenate. In addition, with radiologic findings of multiple cyst lesions in both kidneys and a solid nodule in the left adrenal gland with suspicion of pheochromocytoma, close monitoring by a urologic surgeon was advised.\nAfter three months of follow-up, the patient's main complaints were unstable blood glucose levels with variations of about 60 up to 400 mg/dL and an average of 200 mg/dL checked by a home-use blood glucose meter. Moreover, the patient report having at least three loose bowel movements each day and oftentimes fatty stool (steatorrhea) after overindulging in a high-fat diet. At six months follow-up, the blood glucose was controlled within the range 80-200 mg/dL and could take a normal low-fat diet without steatorrhea.", + "fulltext_subclaims": [ + "A 39-year-old Indonesian male presented to the digestive clinic department with a 7-day history of jaundice.", + "Jaundice was associated with epigastric discomfort, nausea, loss of appetite, and skin itch.", + "He had a history of benign brain tumors and underwent craniotomies three times, at ages 16, 17, and 24.", + "The type of brain tumor and specific procedure are not well known by the patient.", + "Six months before the onset of jaundice, he was diagnosed with diabetes mellitus and began taking oral diabetic medications.", + "Two of the four siblings of the patient have similar conditions.", + "Both of his siblings underwent brain tumor resection, total pancreatectomy, and nephrectomy for Von Hippel-Lindau (VHL)-associated tumors.", + "Physical examination revealed jaundice on the skin and sclera, epigastric pain, and a palpable lump in the epigastric region and both of his flanks.", + "Laboratory workup revealed elevated bilirubin levels, with serum total bilirubin of 6.54 mg/dL and conjugated bilirubin of 5.24 mg/dL.", + "The contrast-enhanced MRI of abdomen with MRCP revealed dilatation of biliary tree consisting of right and left intrahepatic bile duct, common hepatic duct, cystic duct, and common bile duct without the presence of stone.", + "PET/CT scan showed an ametabolic hypodense lesion in the left side of the cerebellum.", + "PET/CT scan showed multiple hypodense nodules or cysts with multiple calcifications covering the entire pancreas.", + "PET/CT scan showed a solid hypermetabolic nodule in the left adrenal gland with suspicious pheochromocytomas.", + "PET/CT scan showed an ametabolic hypodense multiple lesion in both kidneys.", + "All radiologic findings correspond to von-Hippel-Lindau disease.", + "Total pancreatoduodenectomy was decided after considering the lesion in the entire pancreas, which contains solid and cystic nodules.", + "Intraoperatively, it was discovered that the cysts were seen in the entire pancreas with dilatation of biliary tree.", + "Total pancreaticoduodenectomy was performed and followed by reconstruction with end-to-side choledochojejunostomy, side-to-side gastrojejunostomy, and subhepatic drainage was placed.", + "The histopathological findings showed multiple serous cystic neoplasms with calcification.", + "The report further confirmed multicystic pancreatic hamartoma with neuroendocrine cell hyperplasia and the lesion still showed an islet of Langerhans structure.", + "Diagnosis is supported by diffuse positive in Cytokeratin 19 (CK19) and CK7 in cystic lesions.", + "Diagnosis is supported by negative CEA.", + "Diagnosis is supported by positive synaptophysin and chromogranin in nodular lesions.", + "Diagnosis is supported by positive Ki67% (0.2 %) which exclude adenocarcinoma or neuroendocrine tumor findings.", + "The management of the patient is optimally performed by an interprofessional healthcare team.", + "Glycemic control after total pancreatectomy is handled and monitored by an endocrinologist.", + "The insulin regimen prescribed for the patient was as follows: 10 IU of basal insulin taken in the evening, 8 IU and 10 IU of rapid-acting insulin given bolus during breakfast and dinner, respectively.", + "The treatment for exocrine insufficiency was enzyme-substitution drug, which contains amylase, protease, deoxycholic acid, dimethylpolysiloxane, vitamin B1, vitamin B2, vitamin B6, niacinamide, and calcium pantothenate.", + "Close monitoring by a urologic surgeon was advised.", + "After three months of follow-up, the patient's main complaints were unstable blood glucose levels with variations of about 60 up to 400 mg/dL and an average of 200 mg/dL checked by a home-use blood glucose meter.", + "The patient reported having at least three loose bowel movements each day and oftentimes fatty stool (steatorrhea) after overindulging in a high-fat diet.", + "At six months follow-up, the blood glucose was controlled within the range 80-200 mg/dL and could take a normal low-fat diet without steatorrhea." + ], + "summary": "A 39-year-old male with a history of VHL disease and positive family history presented with jaundice and pruritus. He had a history of craniotomy thrice. Laboratory workup revealed elevated total bilirubin level with conjugated bilirubin predominant. The contrast-enhanced MRI showed dilatation of biliary tree with suspicion of partial obstruction by multiple cysts in the pancreas, with ±0.5-5 cm in diameter. A PET/CT scan showed multiple lesions corresponding to VHL disease. The patient underwent total pancreatoduodenectomy. The histopathology finding was multicystic pancreatic hamartoma with neuroendocrine cell hyperplasia.", + "summary_subclaims": [ + "The patient is a 39-year-old male.", + "The patient has a history of VHL disease.", + "The patient has a positive family history.", + "The patient presented with jaundice.", + "The patient presented with pruritus.", + "The patient had a history of craniotomy thrice.", + "The laboratory workup revealed elevated total bilirubin level.", + "The contrast-enhanced MRI showed dilatation of the biliary tree.", + "The contrast-enhanced MRI showed suspicion of partial obstruction by multiple cysts in the pancreas.", + "The multiple cysts in the pancreas were 0.5-5 cm in diameter.", + "A PET/CT scan showed multiple lesions corresponding to VHL disease.", + "The patient underwent total pancreatoduodenectomy.", + "The histopathology finding was multicystic pancreatic hamartoma.", + "The histopathology finding included neuroendocrine cell hyperplasia." + ] + }, + { + "id": "multiclinsum_test_490_en.txt", + "fulltext": "A 62-year-old woman was admitted to our hospital because of mental abnormality and hypomnesia for 3 months. The main mental symptoms were gibberish, irrational talk, impaired mental attention, without apparent hallucinations and delusions. The patient did not present with fluctuating consciousness, lack of consciousness, or loss of consciousness. The family of the patient reported that she had a history of fever before she experienced the mental symptoms. Her highest body temperature was 38.6 °C. Her axillary temperature became normal after she received antibiotic therapy for 4 days. However, she gradually developed symptoms of mental abnormality. She also intermittently complained of abdominal pain, vomiting, constipation, and urinary incontinence for 1 month. She did not experience other discomforts, such as headaches, dizziness, and convulsion. She visited a local hospital in October 2018, and the routine blood test showed that the white blood cell counts were normal, and the percentage of lymphocytes was high. The blood potassium was 1.91 mmol/l (normal 3.5-5.3 mmol/l), and the prolactin level was 90.55 μg/l (normal 2.74–26.72 μg/l). The free thyroxine was slightly high, the thyroglobulin antibody was 12.32 IU/ml (normal 0–115 IU/ml), and the thyroid peroxidase antibody was 10.42 IU/ml (normal 0–34 IU/ml). The testing results of antinuclear antibody, anti-neutrophil cytoplasmic antibody, anti-Jo-1 antibody, anti-dsDNA antibody, anti-Scl-70 antibody, anti-SSA antibody, and anti-SSB antibody were yielded negative, and the tests for hepatitis, HIV, and syphilis virus were also negative. The local hospital suspected intracranial infection, endocrine disease, and electrolyte disorders and gave her symptomatic treatment. Nevertheless, her symptoms showed no noticeable improvement. It was difficult to diagnose the disease, so the patient was admitted to our hospital. The patient had a history of diabetes, hypertension, erosive gastritis, and cataract surgery, but she had no family history of neurological diseases.\nThe physical examination revealed that her body temperature was 36.8 °C, and there was tenderness below the xiphoid. The neurological examination showed impaired mental attention and reaction capacity, slow speech, normal manifestations of the brain nerve, normal muscle strength, and muscle tone, negative meningeal irritation sign and pathological reflex, normal tendon reflex. The patient could not cooperate with the sensory system examination. The mini-mental state examination (MMSE) score was only 6/30.\nEncephalitis was initially suspected, and lumbar puncture was performed. The CSF examination showed that the CSF pressure was 110 mmH2O, and the white blood cell count was normal, but she had an increased total protein level of 0.57 g/l (normal 0.15–0.45 g/l) and a glucose level of 5.10 mmol/l (normal 2.2–3.9 mmol/l). The coxsackie B virus, enterovirus, and cytomegalovirus test levels were normal. Bacterial culture and Cryptococcus neoformans tests were negative. A contrast-enhanced MRI of the brain was normal. The diagnosis of encephalitis was excluded in general. However, leukoencephalopathy was evident on the T2 fluid-attenuated inversion recovery (FLAIR) images. A high-signal intensity in the white matter of the cerebral hemisphere, especially at the subcortex of the frontotemporal and corona radiata, was found on the T2 FLAIR images . The MRI imaging of the left basal ganglia and bilateral corona radiata showed lacunar infarction. Magnetic resonance angiography indicated that the blood vessels were normal. The DWI results revealed a symmetrically distributed strip-shaped high-intensity signal of the corticomedullary junction in the bilateral frontal, parietal, and temporal lobes .\nSkin biopsy samples were obtained at 10 cm above the patient’s ankle. A light microscope was used to examine the samples, which showed hyperkeratosis of the epidermis. A few lymphocytes and tissue cells infiltrated through the superficial vessels of the dermis . Electron microscopy showed round-shaped intranuclear inclusions in the nucleus of the fibrocytes. The intranuclear inclusions had clear borders and were composed of fibrous substances without a membrane structure .\nThe fasting blood glucose was 9.48 mmol/l, and glycosylated hemoglobin was 6.6%. The routine urine test showed normal results. The patient presented with mental abnormality for 3 months. We did not consider the diagnoses of hypoglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic syndrome. Furthermore, the patient did not present with depression, anxiety, consciousness disorders, hallucinations, and neurasthenia, which were common mental symptoms in patients with diabetes. The results of the electrolyte showed hypokalemia (2.6 mmol/L), hyponatremia (127.3 mmol/L), and hypochloremia (86.5 mmol/L). The renin-angiotensin-aldosterone system and cortisol hormone tests showed normal results. The MRI of the hypophysis showed no abnormal areas. The electroencephalography showed low-and moderate-amplitude desynchronized-mixed waves when she fell asleep.\nBrain protection and symptomatic therapy were given when the patient was hospitalized, and the symptoms were relieved. However, she still complained of recurrent vomiting and urinary incontinence. The patient was alive, and the condition of the patient did not worsen or improve for 6 months after she was discharged.", + "fulltext_subclaims": [ + "The patient was a 62-year-old woman.", + "She was admitted to the hospital because of mental abnormality and hypomnesia for 3 months.", + "The main mental symptoms were gibberish, irrational talk, and impaired mental attention.", + "She did not have apparent hallucinations and delusions.", + "She did not present with fluctuating consciousness, lack of consciousness, or loss of consciousness.", + "The family reported that she had a history of fever before the mental symptoms.", + "Her highest body temperature was 38.6 °C.", + "Her axillary temperature became normal after 4 days of antibiotic therapy.", + "She gradually developed symptoms of mental abnormality.", + "She intermittently complained of abdominal pain, vomiting, constipation, and urinary incontinence for 1 month.", + "She did not experience headaches, dizziness, or convulsion.", + "In October 2018, the routine blood test showed normal white blood cell counts.", + "The percentage of lymphocytes was high.", + "The blood potassium was 1.91 mmol/l.", + "The prolactin level was 90.55 μg/l.", + "The free thyroxine was slightly high.", + "The thyroglobulin antibody was 12.32 IU/ml.", + "The thyroid peroxidase antibody was 10.42 IU/ml.", + "The testing results of antinuclear antibody, anti-neutrophil cytoplasmic antibody, anti-Jo-1 antibody, anti-dsDNA antibody, anti-Scl-70 antibody, anti-SSA antibody, and anti-SSB antibody were negative.", + "The tests for hepatitis, HIV, and syphilis virus were negative.", + "The local hospital suspected intracranial infection, endocrine disease, and electrolyte disorders.", + "The patient was admitted to our hospital.", + "The patient had a history of diabetes, hypertension, erosive gastritis, and cataract surgery.", + "The patient had no family history of neurological diseases.", + "The physical examination revealed tenderness below the xiphoid.", + "The neurological examination showed impaired mental attention and reaction capacity.", + "The MMSE score was 6/30.", + "Encephalitis was initially suspected.", + "Lumbar puncture was performed.", + "The CSF pressure was 110 mmH2O.", + "The CSF white blood cell count was normal.", + "The CSF total protein level was 0.57 g/l.", + "The CSF glucose level was 5.10 mmol/l.", + "The coxsackie B virus, enterovirus, and cytomegalovirus test levels were normal.", + "Bacterial culture and Cryptococcus neoformans tests were negative.", + "The contrast-enhanced MRI of the brain was normal.", + "The diagnosis of encephalitis was excluded.", + "Leukoencephalopathy was evident on the T2 FLAIR images.", + "A high-signal intensity in the white matter of the cerebral hemisphere was found on the T2 FLAIR images.", + "The MRI imaging showed lacunar infarction in the left basal ganglia and bilateral corona radiata.", + "Magnetic resonance angiography indicated that the blood vessels were normal.", + "The DWI results revealed symmetrically distributed strip-shaped high-intensity signals in the corticomedullary junction of the bilateral frontal, parietal, and temporal lobes.", + "Skin biopsy samples were obtained at 10 cm above the patient’s ankle.", + "A light microscope showed hyperkeratosis of the epidermis.", + "A few lymphocytes and tissue cells infiltrated through the superficial vessels of the dermis.", + "Electron microscopy showed round-shaped intranuclear inclusions in the nucleus of the fibrocytes.", + "The intranuclear inclusions had clear borders and were composed of fibrous substances without a membrane structure.", + "The fasting blood glucose was 9.48 mmol/l.", + "The glycosylated hemoglobin was 6.6%.", + "The routine urine test showed normal results.", + "The patient did not have hypoglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic syndrome.", + "The patient did not have depression, anxiety, consciousness disorders, hallucinations, or neurasthenia.", + "The electrolyte results showed hypokalemia (2.6 mmol/L), hyponatremia (127.3 mmol/L), and hypochloremia (86.5 mmol/L).", + "The renin-angiotensin-aldosterone system and cortisol hormone tests showed normal results.", + "The MRI of the hypophysis showed no abnormal areas.", + "The electroencephalography showed low-and moderate-amplitude desynchronized-mixed waves when she fell asleep.", + "Brain protection and symptomatic therapy were given.", + "The symptoms were relieved.", + "The patient still complained of recurrent vomiting and urinary incontinence.", + "The patient was alive 6 months after discharge.", + "The condition of the patient did not worsen or improve for 6 months after discharge." + ], + "summary": "A 62-year-old woman presented with mental abnormality and forgetfulness for 3 months before she was admitted to our hospital. There were prodromal symptoms of fever before she had the mental disorder. Encephalitis was first suspected, and the patient underwent lumbar puncture and brain magnetic resonance imaging (MRI). A cerebrospinal fluid (CSF) examination indicated normal pressure, a normal white blood cell count, and slightly elevated protein and glucose levels. Coxsackie B virus, enterovirus, and cytomegalovirus tests showed normal results. Bacterial culture and Cryptococcus neoformans test results were negative. The contrast-enhanced MRI of the brain was normal. The brain diffusion-weighted imaging (DWI) showed a symmetrically distributed strip-shaped hyperintensity signal of the corticomedullary junction in the bilateral frontal, parietal, and temporal lobes. We considered the diagnosis of the NIID, and therefore, skin biopsy was performed. The electron microscopy revealed that intranuclear inclusions in the nucleus of fibrocytes existed and were composed of filaments.", + "summary_subclaims": [ + "The patient is a 62-year-old woman.", + "She presented with mental abnormality and forgetfulness for 3 months.", + "There were prodromal symptoms of fever before she had the mental disorder.", + "Encephalitis was first suspected.", + "The patient underwent lumbar puncture.", + "The patient underwent brain magnetic resonance imaging.", + "Cerebrospinal fluid examination indicated normal pressure.", + "Cerebrospinal fluid examination showed a normal white blood cell count.", + "Cerebrospinal fluid showed slightly elevated protein levels.", + "Cerebrospinal fluid showed slightly elevated glucose levels.", + "Coxsackie B virus tests showed normal results.", + "Enterovirus tests showed normal results.", + "Cytomegalovirus tests showed normal results.", + "Bacterial culture results were negative.", + "Cryptococcus neoformans test results were negative.", + "The contrast-enhanced MRI of the brain was normal.", + "Brain diffusion-weighted imaging showed a symmetrically distributed strip-shaped hyperintensity signal of the corticomedullary junction in the bilateral frontal, parietal, and temporal lobes.", + "The diagnosis of NIID was considered.", + "Skin biopsy was performed.", + "Electron microscopy revealed intranuclear inclusions in the nucleus of fibrocytes.", + "The intranuclear inclusions were composed of filaments." + ] + }, + { + "id": "multiclinsum_test_3083_en.txt", + "fulltext": "2 years 11 months old male pre-schooler admitted to hospital with a 2-month history of abdominal distension and increased abdominal temperature accompanied by pallor. He sought medical attention at the onset of the condition and was prescribed anti-parasitics and ferrous sulphate, which he has been taking since then, without improvement.\n\nA week after admission, a bulge was observed in the left flank region when he sought medical attention again. He underwent abdominal ultrasound, which showed an enlarged left kidney with a globular appearance, with a suggestive image of a coraliform stone inside.\n\nHe was referred to tertiary care, where he presented a regular general condition, hypocratic, tachycardic, with a globose and painful abdomen, with a palpable mass in the left flank and an increase in temperature to the touch in the whole abdominal region. Laboratory tests demonstrated leukocytosis (21,420 leukocytes/mm3), important microcytic anaemia (haemoglobin of 6.3 g/dL and haematocrit of 22.3%), iron deficiency (13.6 mcg/dL), thrombocytosis (757,000 platelets/mm3), an increase in C-reactive protein (16.2 mg/dL) and leukocyturia (28,000 leukocytes/mL). The urine culture showed growth of Proteus mirabilis. The contrast computed tomography of the abdomen showed the presence of a 1.6 cm coraliform renal calculus, marked calicinal dilation and paradoxical renal pelvic contraction, as well as diffuse hypodensity and hyperechoic renal parenchyma, which gave the image a \"bear's paw\" pattern.\n\nPatient underwent left nephrectomy by median laparotomy, under the assumption of xantogranulomatous pyelonephritis. Macroscopically, the left kidney appeared enlarged, with a look of pyelopelvic fat, adhered to the peritoneum, with a highly dilated pyelocalyceal system filled with pus. The anatomopathological study showed a kidney with intense pyelocalyceal dilation and hardened renal parenchyma, with yellowish areas. The microscopic examination revealed extensive chronic inflammation with xantogranulomatous areas coincident with the destruction of the renal parenchyma, with fibrosis and sclerosis of the remaining glomeruli. The conclusion was of xantogranulomatous pyelonephritis associated with pyelopelvic and urolithiasis with coraliform calculus.\n\nHe received 14 days of antibiotic therapy with metronidazole and ceftriaxone and recovered with complete clinical improvement and was discharged in good condition, with no report of recurrence of the condition or change in function in the contralateral kidney in the following year.\n", + "fulltext_subclaims": [ + "The patient is a 2 years 11 months old male pre-schooler.", + "He had a 2-month history of abdominal distension.", + "He had a 2-month history of increased abdominal temperature.", + "He had pallor.", + "He was prescribed anti-parasitics.", + "He was prescribed ferrous sulphate.", + "He has been taking the prescribed medications since the onset of the condition.", + "There was no improvement after taking the prescribed medications.", + "A week after admission, a bulge was observed in the left flank region.", + "He underwent abdominal ultrasound.", + "The ultrasound showed an enlarged left kidney with a globular appearance.", + "The ultrasound showed a suggestive image of a coraliform stone inside the left kidney.", + "He was referred to tertiary care.", + "He presented a regular general condition.", + "He was tachycardic.", + "He had a globose and painful abdomen.", + "A palpable mass was found in the left flank.", + "There was an increase in temperature to the touch in the whole abdominal region.", + "Laboratory tests showed leukocytosis (21,420 leukocytes/mm3).", + "Laboratory tests showed microcytic anaemia (haemoglobin of 6.3 g/dL and haematocrit of 22.3%).", + "Laboratory tests showed iron deficiency (13.6 mcg/dL).", + "Laboratory tests showed thrombocytosis (757,000 platelets/mm3).", + "Laboratory tests showed an increase in C-reactive protein (16.2 mg/dL).", + "The urine culture showed growth of Proteus mirabilis.", + "The contrast computed tomography of the abdomen showed the presence of a 1.6 cm coraliform renal calculus.", + "The contrast computed tomography showed marked calicinal dilation.", + "The contrast computed tomography showed paradoxical renal pelvic contraction.", + "The contrast computed tomography showed diffuse hypodensity and hyperechoic renal parenchyma.", + "The contrast computed tomography showed a 'bear's paw' pattern.", + "The patient underwent left nephrectomy by median laparotomy.", + "The operation was performed under the assumption of xantogranulomatous pyelonephritis.", + "Macroscopically, the left kidney appeared enlarged.", + "The left kidney had a look of pyelopelvic fat.", + "The left kidney was adhered to the peritoneum.", + "The pyelocalyceal system was highly dilated and filled with pus.", + "The anatomopathological study showed intense pyelocalyceal dilation.", + "The anatomopathological study showed hardened renal parenchyma.", + "The anatomopathological study showed yellowish areas.", + "The microscopic examination revealed extensive chronic inflammation.", + "The microscopic examination revealed xantogranulomatous areas.", + "The microscopic examination showed destruction of the renal parenchyma.", + "The microscopic examination showed fibrosis and sclerosis of the remaining glomeruli.", + "The conclusion was xantogranulomatous pyelonephritis.", + "The conclusion was associated with pyelopelvic and urolithiasis with coraliform calculus.", + "The patient received 14 days of antibiotic therapy with metronidazole and ceftriaxone.", + "He recovered with complete clinical improvement.", + "He was discharged in good condition.", + "There was no report of recurrence of the condition in the following year.", + "There was no report of change in function in the contralateral kidney in the following year." + ], + "summary": "2 years and 11 months old male pre-schooler with a 2-month history of distension and abdominal temperature increase and intense pallor, associated with microcytic anaemia refractory to the use of ferrous sulphate. He also presented, one week after admission, a bulge in the left flank region and a palpable mass of hard consistency. Imaging tests (ultrasound and tomography) revealed a global increase in the left kidney, destruction of the renal parenchyma and intense caliceal dilation forming the \"bear's paw\" sign, with the presence of coraliform calculus in the pelvis. He underwent treatment with antibiotic therapy and total nephrectomy, with the product sent to the anatomopathological laboratory.\n", + "summary_subclaims": [ + "The patient is a 2 years and 11 months old male pre-schooler.", + "The patient had a 2-month history of distension.", + "The patient had a 2-month history of abdominal temperature increase.", + "The patient had a 2-month history of intense pallor.", + "The patient had microcytic anaemia.", + "The anaemia was refractory to the use of ferrous sulphate.", + "One week after admission, the patient presented a bulge in the left flank region.", + "One week after admission, the patient had a palpable mass of hard consistency.", + "Imaging tests revealed a global increase in the left kidney.", + "Imaging tests showed destruction of the renal parenchyma.", + "Imaging tests showed intense caliceal dilation forming the 'bear's paw' sign.", + "Imaging tests revealed the presence of a coraliform calculus in the pelvis.", + "The patient underwent treatment with antibiotic therapy.", + "The patient underwent total nephrectomy.", + "The nephrectomy product was sent to the anatomopathological laboratory." + ] + }, + { + "id": "multiclinsum_test_472_en.txt", + "fulltext": "S.F., A 47-year-old nonsmoker woman transferred to the hospital via ambulance and was afterwards admitted for the assessment of chronic and persistent pain in the right foot for a three-months duration associated with significant numbness on the same side. after that, the patient started to complain of acute-onset sever lower back and pelvic pain. She asserted never suffering pain similar to this before. The patient reported no personal and/or family history of cancer, any acute, repeat, or discontinued medications, any allergies, any genetic or psychosocial issues, and had a free past surgical history. physical examination was unremarkable except for lower back tenderness radiated to both lower limbs and marked lower limb weakness with estimated power tone of 2/5 on the right foot. Neurovascular assessment was insignificant. The patient initially underwent spinal computed tomography (CT) without contrast which revealed multiple enhancing metastatic lesions throughout the spine, the most significant lesions are in the thoracic area, particularly at the level of T8-T10 vertebral bodies and mild pathological compression fractures of T4, T5, T9, T10, T11 and L5 associated with a large anterior paraspinal soft tissue component at the same level ( A, B & C). Whole body computed tomography (CT) with intravenous contrast was performed and showed several mixed lytic and sclerotic lesions in the spinal, sternal, and pelvic bones associated with soft tissue component, the largest one seen at the level of T10. CT scan also detected a nodule measuring about 8 mm in right lower lung lobe ( A, B & C). MRI of right foot demonstrated heterogenous, ill defined, lobulated intra muscular mass measuring approximately 3 x 1.7 × 1.3 cm at the planter aspect of the right foot with irregular peripheral post-contrast enhancement ( A, B, C & D). These findings were suggestive of extraskeletal Ewing Sarcoma and to confirm the diagnosis, Excisional biopsy of right foot lesion was taken and showed marked tumor necrosis with numerous mitotic and apoptotic figures. The tumor cells were arranged in an unusual trabecular pattern with rare pseudorosettes (neuroectodermal differentiation) and immunopositivity for CD99 (diffuse-membranous), FLI-1 (nuclear-strong), anti NKx-2.2, Synaptophysin (weak), CD56 (weak), and CKAE1/AE3 (weak-focal) ( A, B, C & D). The diagnosis of extraskeletal Ewing sarcoma of right foot was established. Intravenous oxycodone was administrated to relive patient's sever pain. The patient initially underwent thoraco-lumber pathological fractures fixation with fusion from T2-L1 level, total surgical resection of the foot mass. The procedure was performed by a consultant at spine surgery and spinal deformities department at a private hospital. The patient was started a chemotherapy regimen consisting of carboplatin and paclitaxel weekly. The patient was followed up for 2 months and She adhered to and tolerated the provided advices; avoiding vigorous exercise and heavy lifting. The patient also had a good tolerance of chemotherapy and pharmacological agents without any reported complications or adverse events.", + "fulltext_subclaims": [ + "The patient is a 47-year-old nonsmoker woman.", + "The patient had chronic and persistent pain in the right foot for three months.", + "The patient had significant numbness on the right side.", + "The patient started to complain of acute-onset severe lower back and pelvic pain.", + "The patient asserted never suffering pain similar to this before.", + "The patient reported no personal and/or family history of cancer.", + "The patient reported no acute, repeat, or discontinued medications.", + "The patient reported no allergies.", + "The patient had a free past surgical history.", + "Physical examination was unremarkable except for lower back tenderness radiated to both lower limbs.", + "There was marked lower limb weakness with estimated power tone of 2/5 on the right foot.", + "Neurovascular assessment was insignificant.", + "The patient initially underwent spinal computed tomography (CT) without contrast.", + "Spinal CT revealed multiple enhancing metastatic lesions throughout the spine.", + "The most significant lesions were in the thoracic area, particularly at the level of T8-T10 vertebral bodies.", + "There were mild pathological compression fractures of T4, T5, T9, T10, T11, and L5.", + "There was a large anterior paraspinal soft tissue component at the same level.", + "Whole body CT with intravenous contrast showed several mixed lytic and sclerotic lesions in the spinal, sternal, and pelvic bones.", + "The largest lesion was seen at the level of T10.", + "CT scan detected a nodule measuring about 8 mm in the right lower lung lobe.", + "MRI of the right foot demonstrated a heterogeneous, ill-defined, lobulated intra muscular mass measuring approximately 3 x 1.7 × 1.3 cm at the plantar aspect of the right foot.", + "The mass had irregular peripheral post-contrast enhancement.", + "These findings were suggestive of extraskeletal Ewing Sarcoma.", + "Excisional biopsy of the right foot lesion was taken.", + "The biopsy showed marked tumor necrosis with numerous mitotic and apoptotic figures.", + "The tumor cells were arranged in an unusual trabecular pattern with rare pseudorosettes.", + "The tumor cells showed immunopositivity for CD99 (diffuse-membranous).", + "The tumor cells showed immunopositivity for FLI-1 (nuclear-strong).", + "The tumor cells showed immunopositivity for anti NKx-2.2.", + "The tumor cells showed weak immunopositivity for Synaptophysin.", + "The tumor cells showed weak immunopositivity for CD56.", + "The tumor cells showed weak-focal immunopositivity for CKAE1/AE3.", + "The diagnosis of extraskeletal Ewing sarcoma of the right foot was established.", + "Intravenous oxycodone was administered to relieve the patient's severe pain.", + "The patient initially underwent thoraco-lumbar pathological fractures fixation with fusion from T2-L1 level.", + "The patient underwent total surgical resection of the foot mass.", + "The procedure was performed by a consultant at the spine surgery and spinal deformities department at a private hospital.", + "The patient was started on a chemotherapy regimen consisting of carboplatin and paclitaxel weekly.", + "The patient was followed up for 2 months.", + "The patient adhered to and tolerated the provided advice.", + "The patient avoided vigorous exercise and heavy lifting.", + "The patient had a good tolerance of chemotherapy and pharmacological agents.", + "There were no reported complications or adverse events." + ], + "summary": "A 47-year-old nonsmoking woman was admitted after being transferred from a nearby hospital to check her right foot pain that had been present for three months and was significantly numbing the same side. Only a few lone cases or brief series are reported in the current literature. The typical description of ESs is that they are tiny masses with positive clinical behavior.", + "summary_subclaims": [ + "A 47-year-old nonsmoking woman was admitted after being transferred from a nearby hospital.", + "She was admitted to check her right foot pain that had been present for three months.", + "The right foot pain was significantly numbing the same side.", + "Only a few lone cases or brief series are reported in the current literature.", + "The typical description of ESs is that they are tiny masses with positive clinical behavior." + ] + }, + { + "id": "multiclinsum_test_2196_en.txt", + "fulltext": "A previously healthy, fully immunized 13 years-old boy was transferred to the intensive care unit department of our hospital with drowsiness, progressing painful hyperaemic right periorbital swelling, fever, bilateral nasal obstruction (right > left) and right purulent rhinorrhoea . Moreover, he presented worsening right visual acuity, right dyschromatopsia and a dull cervical pain for 2 days. His mother mentioned us about a right orbital trauma during a sport event (soccer game) occurred 7 days before.\nDuring ENT evaluation anterior rhinoscopy was performed with the finding of scarce purulent discharge from the right nasal cavity, with generalized hyperaemia and swelling of the nasal mucosae. Nasal fiberoptic endoscopy was difficult to perform due to generalized swelling of the nasal mucosae and only revealed right nasopharyngeal purulent drip. Respiratory space revealed normal.\nOn admission blood tests documented leucocytosis with neutrophilia and elevated C-reactive protein (CRP).\nA brain and maxillo-facial contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were performed and revealed the presence of a right intraorbital intraconic abscessual formation , acute right maxillary and left sphenoid sinusitis, minimal clival bone erosion and signs of sigmoid and transverse venous sinuses thrombosis.\nUrgent ophthalmologic evaluation was requested and resulted difficult to be performed due to the minimal palpebral fissure; however, it demonstrated signs of right optic nerve sufferance.\nBased on this finding, a large spectrum intravenous antibiotic treatment with ceftriaxone (2 g twice a day) and metronidazole (500 mg four times a day) and an anticoagulant treatment with subcutaneous low-molecular-weight heparin were introduced.\nThe boy underwent an urgent surgical treatment with drainage of the right intraorbital intraconic abscess via right superior trans-palpebral approach and right antrostomy and left sphenoidotomy via endoscopic sinus surgery (ESS). Microbiological tests of the purulent collection were positive for multisensible Streptococcus intermedius.\nFull recovery of both orbital swelling and nasal complaints was achieved few days after surgery, as well as a progressive improvement with complete recovery in visual acuity.\nAntibiotic treatment with ceftriaxone and metronidazole was continued for 2 weeks, when worsening signs of meningeal sufferance (torcicollis and rigor nucalis), bradycardia and intermittent fever occurred.\nLumbar puncture, abdominal and cardiac ultrasound (US) and blood culture were performed, but all revealed negative for meningitis, further abscessual formations and bacteremia. Immunological tests including immunoglobulins and IgG subclassis, lymphocyte subpopulations, tests for complement function were performed and resulted negative.\nControl head MRI was performed and documented the presence of an abscessual collection of the preclival region extending to the preclival soft tissue posteriorly to the nasopharynx and to the cervical long muscles’ insertion, associated with mandibular, occipital condyles and anterior part of the occipital bone osteomyelitis.\nMultidisciplinary team discussion with neurosurgeon, infectivologist, paediatricians and radiologist was achieved and another surgical urgent procedure was performed: partial posterior septectomy, bilateral sphenoidotomy with access to the preclival compartment and preclival abscess drainage in ESS.\nAntibiotic treatment was changed to vancomycin (40 md\\kg\\die in three doses) and meropenem (100 mg\\kg\\die in three doses) and continued for 34 days with fully complete recovery of the infection and discharged of the patient after ENT, ophthalmologic, neurologic and hematologic controls were referred as negative. Semi-annual imaging with contrasted MRI, as well as ENT, ophthalmologic and neurologist outpatient clinic controls were performed. No recurrences have been detected during the follow-up period (16 months).", + "fulltext_subclaims": [ + "A previously healthy, fully immunized 13 years-old boy was transferred to the intensive care unit department of our hospital.", + "He had drowsiness.", + "He had progressing painful hyperaemic right periorbital swelling.", + "He had fever.", + "He had bilateral nasal obstruction.", + "He had right purulent rhinorrhoea.", + "He had right dyschromatopsia.", + "He had a dull cervical pain for 2 days.", + "His mother mentioned a right orbital trauma during a sport event (soccer game) occurred 7 days before.", + "Anterior rhinoscopy found scarce purulent discharge from the right nasal cavity.", + "Nasal fiberoptic endoscopy was difficult to perform due to generalized swelling of the nasal mucosae.", + "Nasal fiberoptic endoscopy revealed right nasopharyngeal purulent drip.", + "Blood tests documented leucocytosis with neutrophilia.", + "Blood tests documented elevated C-reactive protein (CRP).", + "A brain and maxillo-facial contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were performed.", + "The CT and MRI revealed the presence of a right intraorbital intraconic abscessual formation.", + "The CT and MRI revealed acute right maxillary and left sphenoid sinusitis.", + "The CT and MRI revealed minimal clival bone erosion.", + "The CT and MRI revealed signs of sigmoid and transverse venous sinuses thrombosis.", + "Urgent ophthalmologic evaluation was requested.", + "It was difficult to perform due to the minimal palpebral fissure.", + "It demonstrated signs of right optic nerve sufferance.", + "A large spectrum intravenous antibiotic treatment with ceftriaxone (2 g twice a day) and metronidazole (500 mg four times a day) was introduced.", + "An anticoagulant treatment with subcutaneous low-molecular-weight heparin was introduced.", + "The boy underwent an urgent surgical treatment with drainage of the right intraorbital intraconic abscess via right superior trans-palpebral approach.", + "The boy underwent right antrostomy and left sphenoidotomy via endoscopic sinus surgery (ESS).", + "Microbiological tests of the purulent collection were positive for multisensible Streptococcus intermedius.", + "Full recovery of both orbital swelling and nasal complaints was achieved few days after surgery.", + "There was a progressive improvement with complete recovery in visual acuity.", + "Antibiotic treatment with ceftriaxone and metronidazole was continued for 2 weeks.", + "Worsening signs of meningeal sufferance (torcicollis and rigor nucalis), bradycardia and intermittent fever occurred.", + "Lumbar puncture, abdominal and cardiac ultrasound (US) and blood culture were performed.", + "Lumbar puncture, abdominal and cardiac ultrasound (US) and blood culture were negative for meningitis, further abscessual formations and bacteremia.", + "Immunological tests including immunoglobulins and IgG subclassis, lymphocyte subpopulations, tests for complement function were performed.", + "Immunological tests including immunoglobulins and IgG subclassis, lymphocyte subpopulations, tests for complement function were negative.", + "Control head MRI was performed.", + "The control head MRI documented the presence of an abscessual collection of the preclival region extending to the preclival soft tissue posteriorly to the nasopharynx and to the cervical long muscles’ insertion.", + "The control head MRI documented mandibular, occipital condyles and anterior part of the occipital bone osteomyelitis.", + "A multidisciplinary team discussion with neurosurgeon, infectivologist, paediatricians and radiologist was achieved.", + "Another surgical urgent procedure was performed: partial posterior septectomy, bilateral sphenoidotomy with access to the preclival compartment and preclival abscess drainage in ESS.", + "Antibiotic treatment was changed to vancomycin (40 mg/kg/day in three doses) and meropenem (100 mg/kg/day in three doses).", + "Antibiotic treatment was continued for 34 days.", + "There was a fully complete recovery of the infection.", + "The patient was discharged after ENT, ophthalmologic, neurologic and hematologic controls were referred as negative.", + "Semi-annual imaging with contrasted MRI, as well as ENT, ophthalmologic and neurologist outpatient clinic controls were performed.", + "No recurrences have been detected during the follow-up period (16 months)." + ], + "summary": "A 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis. Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess, left sphenoidal sinusitis, transverse and sigmoid sinus thrombosis. Ophthalmologic evaluation documented a right optic nerve sufferance. Endoscopic and superior right trans-palpebral surgical decompression was performed, and the abscess was drained. Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius. Subsequent prolonged antibiotic and anti-thrombotic treatments were started. In the following two-weeks the sinusal and ophthalmologic clinical conditions improved, whereas the patients complained of mild to moderate cervical pain and suffered from intermittent pyrexia. Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx, associated with mandible osteomyelitis, occipital condyles and anterior part of the temporal bone hyper intensity. Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage. Complete clinical and radiological recovery was achieved after 45 days of medical treatment.", + "summary_subclaims": [ + "A 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis.", + "Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess.", + "Computed tomography and magnetic resonance (MRI) demonstrated left sphenoidal sinusitis.", + "Computed tomography and magnetic resonance (MRI) demonstrated transverse and sigmoid sinus thrombosis.", + "Ophthalmologic evaluation documented a right optic nerve sufferance.", + "Endoscopic and superior right trans-palpebral surgical decompression was performed.", + "The abscess was drained.", + "Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius.", + "Subsequent prolonged antibiotic and anti-thrombotic treatments were started.", + "In the following two-weeks the sinusal and ophthalmologic clinical conditions improved.", + "The patients complained of mild to moderate cervical pain.", + "The patients suffered from intermittent pyrexia.", + "Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx.", + "Control MRI documented mandible osteomyelitis.", + "Control MRI documented occipital condyles and anterior part of the temporal bone hyper intensity.", + "Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage.", + "Complete clinical and radiological recovery was achieved after 45 days of medical treatment." + ] + }, + { + "id": "multiclinsum_test_993_en.txt", + "fulltext": "A 4-year-old Persian boy, 10 kg in weight and diagnosed with MMA, was referred and admitted to our hospital because of progressive lethargy after frequent vomiting since a day before hospitalization and excessive crying and irritability, upward gaze, and muscular hypotonia on the day of hospitalization.\nHe was the second child of healthy, related parents (cousins), born after an uneventful pregnancy and delivery with a birth weight of 2,750 g. His older brother was healthy. His family had a low-class income. His father works at a university and his mother is a housewife. The diagnosis of MMA was made at the age of 3 months on the basis of the clinical presentation and series of laboratory tests (metabolic acidosis, high level of ammonia, and high urinary concentration of methylmalonic acid). The patient had a history of frequent hospitalization owing to imbalanced electrolyte levels and he was regularly taking prescribed medications for 6 months including oral solution of cyanocobalamin 1000 mcg daily, l-carnitine (100 mg/kg/day), Shohl’s solution (sodium citrate) 30 ml every 6 hours.\nUpon the patient’s arrival in the emergency room, owing to abnormal vital signs [temperature (T): 36.3 °C, pulse rate (PR): 280, respiratory rate (RR): 45, blood pressure (BP): 100/90 mmHg, and O2 saturation: 97%]. Electrocardiography (ECG) was performed and showed wide QRS complex ventricular tachycardia .Physical examination revealed pale skin, lethargy, and upward gaze. The muscular examination revealed hypotonia. Neurological examination: all cranial and peripheral nerve examinations were normal. During the present episode, the patient’s laboratory test results were as follows: red blood cell (RBC), 3,530,000/µl; white blood cell (WBC), 8210/µl; hemoglobin (Hb), 9.2 gr/dl; platelet (plt), 375,000/µl; alanine transaminase (ALT), 13; aspartate aminotransferase (AST), 24; alkaline phosphatase (ALP), 499; hepatitis B surface antigen (HBSAg), negative; and human immunodeficiency virus antibody (HIVAb), negative. Urine analysis: WBC, 0–1; RBC, 0; epithelial cell, 1–2; crystals, not seen; cast, not seen; and bacteria, not seen. Arterial blood gases (ABG) revealed severe metabolic acidosis (pH = 7.13, HCO3 = 9.5 mmol/L, pCO2 = 28.1 mmHg), hyperkalemia (K = 8.9 mEq/L, Na = 136 mEq/L), and renal insufficiency (serum creatine levels = 2.3 mg/dl and urea nitrogen = 80 mg/dl). Serum ammonium and lactate level was 95 mcg/dl and 26 mg/dl, respectively. Severe hyperkalemia and metabolic acidosis with respiratory compensation were diagnosed.\nThe patient immediately underwent treatment, including calcium gluconate 10% intravenously infused over 10 minutes, sodium bicarbonate direct intravenous injection (2 mEq/kg) over 5 minutes, hydration with dextrose 10% intravenous serum, and regular insulin intravenous infusion (0.1 ml/kg/hour), and was transferred to the pediatric intensive care unit (PICU) for further assessments. His blood pressure (BP) was 100/70 mmHg, pulse rate was 180/minute and irregular, respiratory rate was 42/minute, body temperature recorded 35.9 °C by skin, pulse oximetry indicated 97% in the PICU. The frequency of ventricular tachycardia gradually decreased and the ECG showed sinus tachycardia. Repeated ABG showed improvement (pH = 7.43, HCO3 = 13.3 mmol/L, pCO2 = 21 mmHg), and serum potassium level came down to 6 mEq/L within the next 6 hours. This management was continued under the observation of a multidisciplinary team. Additionally, kayexalate (10 g every 6 hours) as a sodium potassium exchange resin therapy and MMA formula were added to the treatment routine for the next 2 days. The patient stabilized, serum potassium level reduced to 4.9 mEq/L, serum creatine level reduced to 2.1 mg/dl, and urea nitrogen reduced to 57 mg/dl. It is notable that brain magnetic resonance imaging (MRI) was normal and no growth was observed in patient’s blood culture. He was discharged with a good clinical condition. During the past 6 months, the patient has been regularly monitored every 2 months and has not exhibited any new neurological, cardiological, or other issues. Follow-up is ongoing.", + "fulltext_subclaims": [ + "The patient is a 4-year-old Persian boy.", + "The patient weighs 10 kg.", + "The patient was diagnosed with MMA.", + "The patient was admitted to the hospital because of progressive lethargy.", + "The patient had frequent vomiting since a day before hospitalization.", + "The patient had excessive crying and irritability on the day of hospitalization.", + "The patient had upward gaze on the day of hospitalization.", + "The patient had muscular hypotonia on the day of hospitalization.", + "The patient is the second child of healthy, related parents (cousins).", + "The patient's birth weight was 2,750 g.", + "The patient's older brother is healthy.", + "The patient's family has a low-class income.", + "The patient's father works at a university.", + "The patient's mother is a housewife.", + "The diagnosis of MMA was made at the age of 3 months.", + "The diagnosis was based on clinical presentation and laboratory tests.", + "The patient had a history of frequent hospitalization owing to imbalanced electrolyte levels.", + "The patient was regularly taking prescribed medications for 6 months.", + "The patient was taking oral solution of cyanocobalamin 1000 mcg daily.", + "The patient was taking l-carnitine 100 mg/kg/day.", + "The patient was taking Shohl’s solution 30 ml every 6 hours.", + "Upon arrival in the emergency room, the patient had a pulse rate of 280.", + "Electrocardiography showed wide QRS complex ventricular tachycardia.", + "The patient's physical examination revealed pale skin.", + "The patient's physical examination revealed lethargy.", + "The patient's physical examination revealed upward gaze.", + "The patient's muscular examination revealed hypotonia.", + "The patient's neurological examination showed all cranial and peripheral nerve examinations were normal.", + "The patient's arterial blood gases revealed severe metabolic acidosis (pH = 7.13).", + "The patient's serum potassium level was 8.9 mEq/L.", + "The patient's serum creatine level was 2.3 mg/dl.", + "The patient's urea nitrogen level was 80 mg/dl.", + "The patient was diagnosed with severe hyperkalemia.", + "The patient was diagnosed with metabolic acidosis with respiratory compensation.", + "The patient immediately underwent treatment including calcium gluconate 10% intravenous infusion.", + "The patient received sodium bicarbonate direct intravenous injection.", + "The patient received hydration with dextrose 10% intravenous serum.", + "The patient received regular insulin intravenous infusion.", + "The patient was transferred to the pediatric intensive care unit.", + "Repeated arterial blood gases showed improvement (pH = 7.43).", + "The patient's serum potassium level came down to 6 mEq/L within the next 6 hours.", + "Kayexalate 10 g every 6 hours was added to the treatment routine.", + "MMA formula was added to the treatment routine.", + "The patient's serum potassium level reduced to 4.9 mEq/L.", + "The patient's serum creatine level reduced to 2.1 mg/dl.", + "The patient's urea nitrogen reduced to 57 mg/dl.", + "Brain magnetic resonance imaging was normal.", + "No growth was observed in the patient's blood culture.", + "The patient was discharged with a good clinical condition.", + "During the past 6 months, the patient has been regularly monitored every 2 months.", + "The patient has not exhibited any new neurological, cardiological, or other issues.", + "Follow-up is ongoing." + ], + "summary": "In this paper, we describe a 4-year-old Persian boy with methylmalonic acidemia who developed life-threatening arrhythmia following severe hyperkalemia and metabolic acidosis. Emergent management of the condition was successfully carried out, and the rhythm changed to normal sinus rhythm by effectively reducing the serum potassium level. We discuss the possible etiology of this lethal condition and describe its management on the basis of the available evidence.", + "summary_subclaims": [ + "The patient was a 4-year-old Persian boy.", + "The patient had methylmalonic acidemia.", + "The patient developed life-threatening arrhythmia.", + "The arrhythmia followed severe hyperkalemia and metabolic acidosis.", + "Emergent management of the condition was successfully carried out.", + "The rhythm changed to normal sinus rhythm.", + "The change in rhythm occurred by effectively reducing the serum potassium level.", + "The paper discusses the possible etiology of the lethal condition.", + "The paper describes the management of the condition based on available evidence." + ] + }, + { + "id": "multiclinsum_test_3385_en.txt", + "fulltext": "The patient was an 18-year-old female with Chronic Renal Disease (CRD) on haemodialysis due to probable renal dysplasia, with a history of developmental delay due to hydrocephalus (presenting ventriculoperitoneal shunts). Preoperative and admission chest X-rays were normal. No PPD or IGRA tests were performed as they were not part of the current pre-transplant routine. The recipient did not have a medical history suggestive of tuberculosis.\n\nShe received a kidney transplant from a deceased donor on 10/07/18. The donor was a standard criteria one: 17-year-old male, whose cause of death was suicide (hanging). His creatinine level was 1.55 mg/dL. He was induced with thymoglobulin (panel of antibody reactivity, 29%) and maintained with tacrolimus (0.1 mg/kg), mycophenolate sodium, and prednisone. At the time of donation, there was no report of pulmonary disease and no chest radiographs were performed. The donor did not have a history that suggested the diagnosis of prior TB.\n\nFollowing transplantation, the patient had immediate graft function and was discharged on the seventh postoperative day with creatinine level of 1.16 mg/dL. She was readmitted on the 37th postoperative day with fever and positive cytomegalovirus antigenemia (11 cells) and was treated with ganciclovir for 14 days, but daily fever persisted. Abdominal ultrasound and chest radiographs were normal at this time, and sequential cultures (blood and urine) were positive for Leuconostoc mesenteroides, and she was treated with ampicillin and gentamicin combination, although daily fever persisted.\n\nAfter 2 weeks of admission without resolution of the clinical picture, a computed tomography (CT) of the chest was performed, which revealed diffuse micronodular disease compatible with miliary TB and abdominal fluid adjacent to the middle third of the transplanted kidney; this fluid fistulized through the skin. At this time, the medical team of the contralateral renal transplant was contacted who informed that their patient presented a similar condition, being diagnosed with tuberculosis from the donor and needing to undergo a graft nephrectomy. In addition, this team identified in the donor's history a hospital admission for pneumonia complicated with pleural effusion one month before his death.\n\nOur patient tested positive for Koch's bacillus by polymerase chain reaction (PCR) in urine and positive for alcohol-acid-resistant bacillus (BAAR) in surgical wound drainage fluid. After confirming the diagnosis of TB, the team decided to keep the graft and initiated specific treatment with Coxip (rifampicin, isoniazid, pyrazinamide, and ethambutol) along with the discontinuation of immunosuppressive medication. The Coxip regimen was maintained for 12 months. Prednisone was reintroduced 12 days after the initiation of TB treatment, and the rest of the immunosuppressive medication was resumed after 8 weeks. The creatinine level after the end of TB treatment was 0.85 mg/dL. The patient is currently on outpatient follow-up with tacrolimus, sirolimus, and prednisone and has a creatinine level of 0.76 mg/dL.\n", + "fulltext_subclaims": [ + "The patient was an 18-year-old female with Chronic Renal Disease (CRD) on haemodialysis due to probable renal dysplasia.", + "The patient had a history of developmental delay due to hydrocephalus.", + "Preoperative and admission chest X-rays were normal.", + "No PPD or IGRA tests were performed as they were not part of the current pre-transplant routine.", + "The recipient did not have a medical history suggestive of tuberculosis.", + "She received a kidney transplant from a deceased donor on 10/07/18.", + "The donor was a standard criteria one: 17-year-old male, whose cause of death was suicide (hanging).", + "The donor's creatinine level was 1.55 mg/dL.", + "The donor was induced with thymoglobulin.", + "The donor's panel of antibody reactivity was 29%.", + "The donor was maintained with tacrolimus (0.1 mg/kg), mycophenolate sodium, and prednisone.", + "At the time of donation, there was no report of pulmonary disease.", + "No chest radiographs were performed at the time of donation.", + "The donor did not have a history that suggested the diagnosis of prior TB.", + "Following transplantation, the patient had immediate graft function.", + "She was discharged on the seventh postoperative day with a creatinine level of 1.16 mg/dL.", + "She was readmitted on the 37th postoperative day with fever and positive cytomegalovirus antigenemia (11 cells).", + "She was treated with ganciclovir for 14 days.", + "Daily fever persisted.", + "Abdominal ultrasound and chest radiographs were normal at this time.", + "Sequential cultures (blood and urine) were positive for Leuconostoc mesenteroides.", + "She was treated with ampicillin and gentamicin combination.", + "After 2 weeks of admission without resolution of the clinical picture, a computed tomography (CT) of the chest was performed.", + "The CT revealed diffuse micronodular disease compatible with miliary TB.", + "The CT revealed abdominal fluid adjacent to the middle third of the transplanted kidney.", + "The abdominal fluid fistulized through the skin.", + "The medical team of the contralateral renal transplant was contacted.", + "The contralateral team informed that their patient presented a similar condition.", + "The contralateral team diagnosed tuberculosis from the donor.", + "The contralateral team identified in the donor's history a hospital admission for pneumonia complicated with pleural effusion one month before his death.", + "Our patient tested positive for Koch's bacillus by polymerase chain reaction (PCR) in urine.", + "Our patient tested positive for alcohol-acid-resistant bacillus (BAAR) in surgical wound drainage fluid.", + "After confirming the diagnosis of TB, the team decided to keep the graft.", + "The team initiated specific treatment with Coxip (rifampicin, isoniazid, pyrazinamide, and ethambutol).", + "The Coxip regimen was maintained for 12 months.", + "Immunosuppressive medication was discontinued.", + "Prednisone was reintroduced 12 days after the initiation of TB treatment.", + "The rest of the immunosuppressive medication was resumed after 8 weeks.", + "The creatinine level after the end of TB treatment was 0.85 mg/dL.", + "The patient is currently on outpatient follow-up with tacrolimus, sirolimus, and prednisone.", + "The patient's current creatinine level is 0.76 mg/dL." + ], + "summary": "An 18-year-old female who underwent a renal transplant from a deceased donor and was discharged with adequate renal function was readmitted on the 37th day of postoperative care with fever. A CT scan showed signs of miliary TB and fluid collection as well as fistulization of the graft through the skin. The patient was positive for BAAR in the drained fluid and Koch bacillus in the urine. She was treated with a four-drug regimen (rifampicin, isoniazid, pyrazinamide, and ethambutol) with an excellent response and preserved graft function. We were informed that the recipient of the contralateral kidney also developed post-transplant TB, implying a donor-derived origin.\n", + "summary_subclaims": [ + "The patient is an 18-year-old female.", + "She underwent a renal transplant from a deceased donor.", + "She was discharged with adequate renal function.", + "She was readmitted on the 37th day of postoperative care.", + "She had fever.", + "A CT scan showed signs of miliary TB.", + "A CT scan showed fluid collection.", + "A CT scan showed fistulization of the graft through the skin.", + "The patient was positive for BAAR in the drained fluid.", + "The patient was positive for Koch bacillus in the urine.", + "She was treated with a four-drug regimen.", + "The regimen included rifampicin.", + "The regimen included isoniazid.", + "The regimen included pyrazinamide.", + "The regimen included ethambutol.", + "She had an excellent response.", + "Graft function was preserved.", + "The recipient of the contralateral kidney also developed post-transplant TB.", + "This implied a donor-derived origin." + ] + }, + { + "id": "multiclinsum_test_576_en.txt", + "fulltext": "A 21-year-old man, with a previous diagnosis of HHT and embolization of multiple P-AVM in the past, was admitted at another hospital, while on holidays, with fever, headache and malaise. A non-enhanced computed tomography (CT) of the head showed no significant findings. He was diagnosed with typhoid fever based on clinical features and serology. Consequently, he was discharged with oral antibiotic therapy consisting of ciprofloxacin 500 mg bid and cotrimoxazole 800/160 mg bid.\nTwo weeks later, he came to our emergency department because of the persistent fever and headache. At our center, the neurologic, cardiac and pulmonary examination were normal. Routine hematology showed a white cell count of 17.6 × 103/ml leucocytes (4.0–11.5) and 14.33 × 103/ml neutrophils (1.5–7.5). The C-reactive protein was 2.00 mg/L (0.1–10) and the arterial blood gases were normal. A chest radiograph appeared to be normal other than visualization of previous embolization material .\nA contrast-enhanced CT scanner of the head revealed a mass in the right thalamic-capsular region, compatible with an abscess. An MRI, performed later, confirmed the findings showing the typical ring-like contrast enhancement.\nFurther investigations were performed. A cardiac transesophageal echography was normal. A CT of his lungs confirmed the presence of embolization material inside the lumen of pulmonary vessels feeding the malformations. After reviewing the images with our radiology team, they concluded that the lesions were successfully treated. Pulmonary angiography was not performed in light of these results and because our patient was being followed for that pathology in another center.", + "fulltext_subclaims": [ + "The patient is a 21-year-old man.", + "He has a previous diagnosis of HHT.", + "He had embolization of multiple P-AVM in the past.", + "He was admitted at another hospital while on holidays.", + "He had fever, headache, and malaise.", + "A non-enhanced CT of the head showed no significant findings.", + "He was diagnosed with typhoid fever based on clinical features and serology.", + "He was discharged with oral antibiotic therapy.", + "The oral antibiotic therapy consisted of ciprofloxacin 500 mg bid.", + "The oral antibiotic therapy also included cotrimoxazole 800/160 mg bid.", + "Two weeks later, he came to our emergency department.", + "He had persistent fever and headache.", + "The neurologic, cardiac, and pulmonary examination were normal.", + "The white cell count was 17.6 × 103/ml leucocytes.", + "The C-reactive protein was 2.00 mg/L.", + "A contrast-enhanced CT scanner of the head revealed a mass in the right thalamic-capsular region.", + "The mass was compatible with an abscess.", + "An MRI confirmed the findings.", + "The MRI showed the typical ring-like contrast enhancement.", + "A cardiac transesophageal echography was normal.", + "A CT of his lungs confirmed the presence of embolization material inside the lumen of pulmonary vessels.", + "The radiology team concluded that the lesions were successfully treated.", + "Pulmonary angiography was not performed." + ], + "summary": "We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance.", + "summary_subclaims": [ + "The patient is a 21-year-old.", + "The patient had a right thalamic abscess.", + "The abscess was due to HHT and pulmonary arteriovenous malformations.", + "The pulmonary arteriovenous malformations had been previously embolized.", + "The patient was treated solely with antibiotics.", + "The possibility of a stereotaxic biopsy was contemplated.", + "The high-risk location of the abscess was noted.", + "The patient had received a previous full course of antibiotic treatment at another center.", + "The decision was made to discard the stereotaxic biopsy.", + "The decision was based on the low diagnostic yield.", + "An empiric antibiotic regime was started.", + "Clinical and radiological evaluations were followed up very closely in the next weeks.", + "Antibiotic treatment was adjusted when necessary.", + "The results were favorable from both the radiological and clinical aspects.", + "Six months after the diagnosis, the images showed almost complete disappearance of the abscess." + ] + }, + { + "id": "multiclinsum_test_2222_en.txt", + "fulltext": "Ms. B is an 86-year-old woman who presented with a four-day history of obstipation, anorexia, nausea, and vomiting associated with worsening colicky abdominal pain and postprandial reflux. Her past medical history included Kaposi sarcoma, hypertension, osteoarthritis, and vitamin D deficiency. Although she had acute cholecystitis in the past, cholecystectomy had not been performed. Her surgical history included caesarean section through a lower abdominal midline incision and tonsillectomy. She lived alone and was independent with her daily activities of living.\nOn examination, all the vital signs were within the normal range. Her abdomen was distended and tender on palpation as well as percussion, particularly in the lower abdomen. There was also guarding in the same region. Bowel sounds were present. On initial laboratory evaluation, she had mildly elevated inflammatory markers with white cell count of 15.6 [4.0–11.0 × 109/L], C-reactive protein (CRP) of 67 [<6.0 mg/L]. Her liver function tests showed bilirubin of 25 [2-20 μmol], alanine aminotransferase (ALT) of 18 [<33 U/L], alkaline phosphatase (ALP) of 135 [30-110 U/L], and gamma-glutamyl transpeptidase (GGT) of 56 [<56 U/L], indicating an obstructive pattern of the liver enzyme derangements. Other laboratory abnormalities were creatinine of 99 [45-90 μmol/L] and urea of 8.6 [2.5-7.5 mmol/L], indicating mild acute kidney injury in the context of her reduced food intake and dehydration. Her other serum electrolytes were normal. The urinalysis was unremarkable.\nOn her computed tomography (CT) scan of her abdomen and pelvis, there were two gall stones of 3 cm and 3.3 cm lodged in the proximal duodenum and distal colon, respectively . It also showed a contracted and inflamed gallbladder with gas in the biliary tree. Along with the gallstones, the presence of pneumobilia was consistent with the presence of fistula originating from the gallbladder. The common bile duct (CBD) was dilated, measuring 17 mm. The diagnosis of Bouveret syndrome with gallstone coleus was made.\nWhile resuscitating with intravenous fluids, a nasogastric tube was inserted. Intravenous antibiotics (Ampicillin, Gentamicin, and Metronidazole) were commenced. The patient was consented for a laparotomy for removal of the gall stones and a potential bowel resection with stoma formation. Laparoscopic approach was not considered due to its technical difficulty with manoeuvring the gallstones and the likely presence of intra-abdominal adhesions.\nThe laparotomy revealed two points of obstruction at the first part of the duodenum and at the distal sigmoid colon . An attempt was made to manually move the stone in the duodenum into the distended stomach but was unsuccessful. Following a duodenotomy, the duodenal stone was extracted. The sigmoid colon was distended proximal to the second stone. An indurated segment of the sigmoid colon was found distal to the stone. The cholecystocolonic fistula was not found. Similarly, a colotomy was made to remove the stone. There were no intraluminal pathology including strictures and masses identified. Both of the gallstones were removed via longitudinal incisions. The duodenotomy and colotomy were primarily closed transversely using PDS in a single layer. Duodenal repair was reinforced with an omental patch. There were severe inflammatory changes in the right upper quadrant involving the gall bladder and the second part of the duodenum, which were more in favour of a cholecystoduodenal fistula over a choledocoduodenal fistula.\nOn examination of the rest of the bowel, it was grossly normal except for multiple diverticulae in the left-sided large bowel. They were relatively small and uncomplicated diverticulae. The cause of the dilated CBD was not found. The cholecystectomy, resection of the fistula, and CBD exploration were not performed due to the unclear anatomy intraoperatively as well as patient comorbidities, making the risk of complications high.\nHer immediate postoperative recovery was uncomplicated. She did not require inotropic or ventilator support. Her diet was slowly progressed. The patient was subsequently discharged to the care of her family and followed up in the general surgery clinic.", + "fulltext_subclaims": [ + "Ms. B is an 86-year-old woman.", + "She presented with a four-day history of obstipation.", + "She had anorexia.", + "She had nausea.", + "She had vomiting.", + "She had worsening colicky abdominal pain.", + "She had postprandial reflux.", + "Her past medical history included Kaposi sarcoma.", + "Her past medical history included hypertension.", + "Her past medical history included osteoarthritis.", + "Her past medical history included vitamin D deficiency.", + "She had acute cholecystitis in the past.", + "Cholecystectomy had not been performed.", + "Her surgical history included caesarean section through a lower abdominal midline incision.", + "Her surgical history included tonsillectomy.", + "She lived alone.", + "She was independent with her daily activities of living.", + "On examination, all the vital signs were within the normal range.", + "Her abdomen was distended.", + "Her abdomen was tender on palpation.", + "Her abdomen was tender on percussion.", + "There was guarding in the lower abdomen.", + "Bowel sounds were present.", + "On initial laboratory evaluation, she had a white cell count of 15.6 × 109/L.", + "Her C-reactive protein was 67 mg/L.", + "Her bilirubin was 25 μmol/L.", + "Her alkaline phosphatase was 135 U/L.", + "Her gamma-glutamyl transpeptidase was 56 U/L.", + "Her creatinine was 99 μmol/L.", + "Her urea was 8.6 mmol/L.", + "The CT scan showed two gall stones of 3 cm and 3.3 cm lodged in the proximal duodenum and distal colon, respectively.", + "The CT scan showed a contracted and inflamed gallbladder with gas in the biliary tree.", + "The common bile duct was dilated, measuring 17 mm.", + "The diagnosis of Bouveret syndrome with gallstone ileus was made.", + "Intravenous antibiotics (Ampicillin, Gentamicin, and Metronidazole) were commenced.", + "The patient was consented for a laparotomy for removal of the gall stones and a potential bowel resection with stoma formation.", + "The laparotomy revealed two points of obstruction at the first part of the duodenum and at the distal sigmoid colon.", + "An attempt was made to manually move the stone in the duodenum into the distended stomach but was unsuccessful.", + "Following a duodenotomy, the duodenal stone was extracted.", + "An indurated segment of the sigmoid colon was found distal to the stone.", + "A colotomy was made to remove the stone.", + "Both of the gallstones were removed via longitudinal incisions.", + "The duodenotomy and colotomy were primarily closed transversely using PDS in a single layer.", + "Duodenal repair was reinforced with an omental patch.", + "The cause of the dilated CBD was not found.", + "The cholecystectomy, resection of the fistula, and CBD exploration were not performed.", + "Her immediate postoperative recovery was uncomplicated.", + "She did not require inotropic or ventilator support.", + "The patient was discharged to the care of her family." + ], + "summary": "Ms. B is an 86-year-old woman of Italian background who presented to our emergency department with worsening symptoms of bowel obstruction. Her past clinical history included Kaposi sarcoma, hypertension, osteoarthritis, and vitamin D deficiency with surgical history including caesarean section and tonsillectomy. On her imaging, she had two large gallstones, one in the proximal duodenum and one in the distal colon. It also showed gastric dilatation and gas in the gall bladder. She was subsequently diagnosed with Bouveret syndrome with concurrent gallstone coleus. The laparotomy revealed two points of gallstone obstruction at the first part of the duodenum and at the distal sigmoid colon. Her postoperative recovery was uncomplicated. She was discharged to the care of her family and followed up in the general surgery clinic.", + "summary_subclaims": [ + "The patient is an 86-year-old woman of Italian background.", + "She presented to the emergency department with worsening symptoms of bowel obstruction.", + "Her past clinical history included Kaposi sarcoma.", + "Her past clinical history included hypertension.", + "Her past clinical history included osteoarthritis.", + "Her past clinical history included vitamin D deficiency.", + "Her surgical history included caesarean section.", + "Her surgical history included tonsillectomy.", + "Imaging showed two large gallstones.", + "One gallstone was in the proximal duodenum.", + "One gallstone was in the distal colon.", + "Imaging showed gastric dilatation.", + "Imaging showed gas in the gall bladder.", + "She was diagnosed with Bouveret syndrome.", + "She was diagnosed with concurrent gallstone ileus.", + "Laparotomy revealed two points of gallstone obstruction.", + "One point of obstruction was at the first part of the duodenum.", + "One point of obstruction was at the distal sigmoid colon.", + "Her postoperative recovery was uncomplicated.", + "She was discharged to the care of her family.", + "She was followed up in the general surgery clinic." + ] + }, + { + "id": "multiclinsum_test_3013_en.txt", + "fulltext": "An 84-year-old man presented to the emergency room with gross haematochezia for several days and shortness of breath for 1 month. His medical history was significant for deep vein thrombosis (DVT) on warfarin, hypertension, hyperlipidemia, diabetes mellitus and chronic kidney disease.\n\n\nInvestigations\n\nBloodwork was obtained, and his haemoglobin level was 86 g/L, mean corpuscular volume was 92.1 fL international normalised ratio was 3.4, serum creatinine was 1.5 mg/dL, albumin was 2.7 g/dL and liver function tests were normal. His vital signs were within normal limits.\n\nHe was transfused one unit of blood, warfarin was held and he received 10 mg of intramuscular vitamin K. CT showed circumferential thickening of the ascending colon. Colonoscopy confirmed a circumferential, friable mass in the ascending colon. Biopsies demonstrated poorly differentiated adenocarcinoma, and mismatch repair testing showed loss of expression of MLH1 and PMS2. Serum carcinoembryonic antigen was normal at <0.5 ng/mL. Lower extremity duplex demonstrated no acute DVT, and anticoagulation was discontinued. Haemoglobin was 87 g/L at discharge and he had no further haematochezia or melena.\n\nThe patient was referred to surgical oncology clinic, where he reported dyspnea with minimal exertion and appeared short of breath. Electrocardiogram demonstrated T-wave inversion in the lateral leads, and echocardiogram showed an ejection fraction of 41% with akinesis of the basal anterolateral and mid-anterior walls. He was evaluated by cardiology and was initiated on diuretics. The diagnostic and therapeutic treatment of choice was coronary angiogram with percutaneous coronary intervention, but this intervention was contraindicated in the presence of active gastrointestinal bleeding since placement of a stent would require dual antiplatelet therapy which could exacerbate bleeding.\n\n\nTreatment\n\nThe patient was discussed at a high-risk anaesthesia multidisciplinary conference. All attendees agreed that the patient’s poor cardiac status was risk prohibitive for an upfront colectomy and he was referred to radiation oncology for treatment of bleeding prior to coronary intervention. Because the patient was not a candidate for chemotherapy, he received a palliative dose of 30 Gy of external beam radiation in 10 fractions without complication.\n\nThe patient had no further haematochezia and his symptoms improved with diuresis. He underwent coronary angiogram which showed two-vessel disease with an occluded proximal left anterior descending artery which was treated with a bare metal stent. He received dual antiplatelet therapy for 4 weeks, and then continued aspirin alone.\n\nThe patient was re-evaluated in surgical oncology clinic and appeared to be an appropriate surgical candidate after these interventions. Repeat staging CT showed no evidence of metastatic disease and improvement in colonic thickening. After discussion with the patient and his family, and consultation with the anaesthesia and cardiology teams, resection was recommended due to the potential risk for bleeding and obstruction if the tumour was left in situ. Six months after initial diagnosis, the patient underwent robotic-assisted right hemicolectomy with an intracorporeal ileocolic anastomosis. He had an uneventful postoperative course and was discharged on postoperative day 3. Final pathology demonstrated complete pathologic response with no residual tumour, and no tumour in 18 lymph nodes harvested.\n\nThe patient did not require adjuvant chemotherapy.\n\n\nOutcome and follow-up\n\nThe patient is alive and doing well from a cardiac standpoint with no evidence of disease recurrence at 12 months after surgery and 18 months after initial cancer diagnosis.", + "fulltext_subclaims": [ + "The patient was an 84-year-old man.", + "He presented to the emergency room with gross haematochezia for several days.", + "He had shortness of breath for 1 month.", + "His medical history was significant for deep vein thrombosis (DVT) on warfarin.", + "His haemoglobin level was 86 g/L.", + "His international normalised ratio was 3.4.", + "CT showed circumferential thickening of the ascending colon.", + "Colonoscopy confirmed a circumferential, friable mass in the ascending colon.", + "Biopsies demonstrated poorly differentiated adenocarcinoma.", + "Mismatch repair testing showed loss of expression of MLH1 and PMS2.", + "Serum carcinoembryonic antigen was normal at <0.5 ng/mL.", + "Lower extremity duplex demonstrated no acute DVT.", + "Anticoagulation was discontinued.", + "The patient was referred to surgical oncology clinic.", + "He reported dyspnea with minimal exertion.", + "Electrocardiogram demonstrated T-wave inversion in the lateral leads.", + "Echocardiogram showed an ejection fraction of 41%.", + "The diagnostic and therapeutic treatment of choice was coronary angiogram with percutaneous coronary intervention.", + "This intervention was contraindicated in the presence of active gastrointestinal bleeding.", + "The patient was discussed at a high-risk anaesthesia multidisciplinary conference.", + "All attendees agreed that the patient’s poor cardiac status was risk prohibitive for an upfront colectomy.", + "He received a palliative dose of 30 Gy of external beam radiation in 10 fractions.", + "He had no further haematochezia.", + "He underwent coronary angiogram which showed two-vessel disease.", + "The proximal left anterior descending artery was treated with a bare metal stent.", + "He received dual antiplatelet therapy for 4 weeks.", + "He continued aspirin alone.", + "The patient was re-evaluated in surgical oncology clinic.", + "Repeat staging CT showed no evidence of metastatic disease.", + "Resection was recommended due to the potential risk for bleeding and obstruction if the tumour was left in situ.", + "The patient underwent robotic-assisted right hemicolectomy.", + "He had an uneventful postoperative course.", + "Final pathology demonstrated complete pathologic response with no residual tumour.", + "No tumour was found in 18 lymph nodes harvested.", + "The patient did not require adjuvant chemotherapy.", + "The patient is alive and doing well from a cardiac standpoint.", + "There was no evidence of disease recurrence at 12 months after surgery.", + "There was no evidence of disease recurrence at 18 months after initial cancer diagnosis." + ], + "summary": "An 84-year-old man with a history of deep vein thrombosis on warfarin and coronary artery disease presented with haematochezia and was diagnosed with an ascending colon cancer. He was short of breath with lower extremity oedema at the initial surgical consultation. Evaluation revealed an acute exacerbation of congestive heart failure, and further workup and treatment were recommended by the cardiology team. After multidisciplinary discussion, he underwent radiation for the control of bleeding, followed by cardiac catheterisation and placement of a bare metal stent. The patient subsequently underwent robotic-assisted right hemicolectomy. Pathology demonstrated a complete response, and the patient recovered uneventfully. He is alive swith no evidence of disease recurrence 12 months after surgery and 18 months after initial diagnosis.", + "summary_subclaims": [ + "The patient is an 84-year-old man.", + "He has a history of deep vein thrombosis.", + "He is on warfarin.", + "He has coronary artery disease.", + "He presented with haematochezia.", + "He was diagnosed with ascending colon cancer.", + "He was short of breath.", + "He had lower extremity oedema at the initial surgical consultation.", + "Evaluation revealed an acute exacerbation of congestive heart failure.", + "Further workup and treatment were recommended by the cardiology team.", + "After multidisciplinary discussion, he underwent radiation for the control of bleeding.", + "He underwent cardiac catheterisation.", + "A bare metal stent was placed.", + "He underwent robotic-assisted right hemicolectomy.", + "Pathology demonstrated a complete response.", + "The patient recovered uneventfully.", + "He is alive with no evidence of disease recurrence 12 months after surgery.", + "He is alive with no evidence of disease recurrence 18 months after initial diagnosis." + ] + }, + { + "id": "multiclinsum_test_2766_en.txt", + "fulltext": "A 70-year-old woman of Iranian descent was referred to our trauma unit for a major scald burn. The exact mechanism of injury was inconclusive. The patient had a history of diabetes mellitus type 2, ischemic heart disease, hypertension, hyperparathyroidism, hyperlipidemia, chronic bronchitis, glaucoma, and mild depressive disorder. She had been receiving treatment on a regular basis with the following medications: amitriptyline, enalapril, glyburide, verapamil, omeprazole, aspirin, simvastatin, theophylline, furosemide, metformin, citropram, dorzolamide hydrochloride eye drops, and latanoprost eye drops.\nOn admission, the patient was disoriented. Blood pressure was 90/60 mmHg. Cutaneous examination revealed a second-degree superficial burn involving both breasts, lateral aspect of the flanks, anteromedial aspect of the arms, medial aspect of the thighs, and the right scapular region. Diffuse erythema was noted, especially of the upper extremity and anterior trunk .\nA presumptive diagnosis of a second-degree, superficial major scald burn affecting 26% of the total body surface area (TBSA) was made. Fluid resuscitation was initiated according to the Parkland formula . A Foley catheter was inserted. Local treatment included wound debridement and application of saline-soaked gauze.\nPhysician examination 12 hours post-admission to the Burn Unit was remarkable for thin blisters in locations not affected on admission: back, neck, inguinal region, and both knees , ultimately effecting 35% of the TBSA. The worsened epidermolysis was accompanied by a positive Nikolsky sign.\nOn further questioning, burn was ruled out as a causal factor. The patient reported that 2 days prior to admission, she had been discharged from another hospital with a diagnosis of pneumonia, and she had been receiving ceftriaxone for 4 days.\nThe final diagnosis was TEN due to ceftriaxone intake. The mucous membranes were not involved. Treatment with intravenous hydrocortisone 500 mg was initiated. The hypoglycemia (glucose level-45 mg/dl) was successfully treated with intravenous dextrose 5%, and the oral hypoglycemic medications were discontinued. Laboratory studies revealed hypomagnesemia (1.32 mg/dl), for which intravenous MgS04 was administered. Local treatment included Vaseline gauze dressings that were changed once a day.\nOn the second day of admission, the patient's temperature began to rise. Complete blood count revealed leukopenia of 2,300 mg/dl. Incisional punch biopsy demonstrated widespread full-thickness epidermal necrosis . The dermis was devoid of inflammatory cells. Histopathological findings were compatible with the diagnosis of TEN. The patient was referred to our intensive care unit (ICU), and treatment with intravenous immunoglobulins (IVIG) was initiated (0.5 g/kg daily for 4 days, the total daily dose of IVIG was 40 grams). The hemodynamic instability was successfully treated with inotropic agents and mechanical ventilation.\nBlood culture results, obtained during the patient's hospitalization in the ICU, were positive for Klebsiella pneumoniae, Proteus mirabilis, Enterobacter, Enterococcus and Pseudomonas aeruginosa. Antibiotic treatment included vancomycin, levofloxacin, ciprofloxacin, ampicillin sulbactam, piperacillin tazobactam, and amikacin sulfate. The clinical course was complicated by adult respiratory distress syndrome, thrombocytopenia, and hypoglycemic episodes. Following prolonged ventilation, tracheostomy was performed. After 42 days in the ICU, the patient was found to be hemodynamically stable and afebrile, and was discharged to rehabilitation. Study of the cutaneous lesions demonstrated re-epithelization with successful wound healing. Mild pigmentary alterations remained with no residual scars. Despite the favorable course of TEN in this case, the patient succumbed to intracranial hemorrhage 4 months later. This outcome was entirely unrelated to TEN.", + "fulltext_subclaims": [ + "The patient was a 70-year-old woman of Iranian descent.", + "The patient was referred to the trauma unit for a major scald burn.", + "The exact mechanism of injury was inconclusive.", + "The patient had a history of diabetes mellitus type 2.", + "The patient had a history of ischemic heart disease.", + "The patient had a history of hypertension.", + "The patient had a history of hyperparathyroidism.", + "The patient had a history of hyperlipidemia.", + "The patient had a history of chronic bronchitis.", + "The patient had a history of glaucoma.", + "The patient had a history of mild depressive disorder.", + "The patient had been receiving treatment with amitriptyline.", + "The patient had been receiving treatment with enalapril.", + "The patient had been receiving treatment with glyburide.", + "The patient had been receiving treatment with verapamil.", + "The patient had been receiving treatment with omeprazole.", + "The patient had been receiving treatment with aspirin.", + "The patient had been receiving treatment with simvastatin.", + "The patient had been receiving treatment with theophylline.", + "The patient had been receiving treatment with furosemide.", + "The patient had been receiving treatment with metformin.", + "The patient had been receiving treatment with citropram.", + "The patient had been receiving treatment with dorzolamide hydrochloride eye drops.", + "The patient had been receiving treatment with latanoprost eye drops.", + "On admission, the patient was disoriented.", + "Blood pressure was 90/60 mmHg.", + "Cutaneous examination revealed a second-degree superficial burn involving both breasts.", + "Cutaneous examination revealed a second-degree superficial burn involving the lateral aspect of the flanks.", + "Cutaneous examination revealed a second-degree superficial burn involving the anteromedial aspect of the arms.", + "Cutaneous examination revealed a second-degree superficial burn involving the medial aspect of the thighs.", + "Cutaneous examination revealed a second-degree superficial burn involving the right scapular region.", + "Diffuse erythema was noted, especially of the upper extremity.", + "A presumptive diagnosis of a second-degree, superficial major scald burn affecting 26% of the total body surface area was made.", + "Fluid resuscitation was initiated according to the Parkland formula.", + "A Foley catheter was inserted.", + "Local treatment included wound debridement.", + "Local treatment included application of saline-soaked gauze.", + "Physician examination 12 hours post-admission to the Burn Unit was remarkable for thin blisters in locations not affected on admission.", + "The worsened epidermolysis was accompanied by a positive Nikolsky sign.", + "On further questioning, burn was ruled out as a causal factor.", + "The patient reported that 2 days prior to admission, she had been discharged from another hospital with a diagnosis of pneumonia.", + "The patient had been receiving ceftriaxone for 4 days.", + "The final diagnosis was TEN due to ceftriaxone intake.", + "The mucous membranes were not involved.", + "Treatment with intravenous hydrocortisone 500 mg was initiated.", + "The hypoglycemia (glucose level-45 mg/dl) was successfully treated with intravenous dextrose 5%.", + "The oral hypoglycemic medications were discontinued.", + "Laboratory studies revealed hypomagnesemia (1.32 mg/dl).", + "Intravenous MgS04 was administered.", + "Local treatment included Vaseline gauze dressings that were changed once a day.", + "On the second day of admission, the patient's temperature began to rise.", + "Complete blood count revealed leukopenia of 2,300 mg/dl.", + "Incisional punch biopsy demonstrated widespread full-thickness epidermal necrosis.", + "The dermis was devoid of inflammatory cells.", + "Histopathological findings were compatible with the diagnosis of TEN.", + "The patient was referred to the intensive care unit.", + "Treatment with intravenous immunoglobulins (IVIG) was initiated.", + "The hemodynamic instability was successfully treated with inotropic agents and mechanical ventilation.", + "Blood culture results were positive for Klebsiella pneumoniae.", + "Blood culture results were positive for Proteus mirabilis.", + "Blood culture results were positive for Enterobacter.", + "Blood culture results were positive for Enterococcus.", + "Blood culture results were positive for Pseudomonas aeruginosa.", + "Antibiotic treatment included vancomycin.", + "Antibiotic treatment included levofloxacin.", + "Antibiotic treatment included ciprofloxacin.", + "Antibiotic treatment included ampicillin sulbactam.", + "Antibiotic treatment included piperacillin tazobactam.", + "Antibiotic treatment included amikacin sulfate.", + "The clinical course was complicated by adult respiratory distress syndrome.", + "The clinical course was complicated by thrombocytopenia.", + "The clinical course was complicated by hypoglycemic episodes.", + "Following prolonged ventilation, tracheostomy was performed.", + "After 42 days in the ICU, the patient was found to be hemodynamically stable.", + "After 42 days in the ICU, the patient was found to be afebrile.", + "The patient was discharged to rehabilitation.", + "Study of the cutaneous lesions demonstrated re-epithelization with successful wound healing.", + "Mild pigmentary alterations remained with no residual scars.", + "The patient succumbed to intracranial hemorrhage 4 months later.", + "This outcome was entirely unrelated to TEN." + ], + "summary": "We present a 70-year-old woman of Iranian descent who presented with toxic epidermal necrolysis that was initially diagnosed as a scald burn. Further anamnesis prompted by spread of the lesions during hospitalization revealed that the patient had been receiving ceftriaxone for several days. To the best of our knowledge, this is the first case of ceftriaxone-induced toxic epidermal necrolysis in the English literature.", + "summary_subclaims": [ + "The patient is a 70-year-old woman of Iranian descent.", + "The patient presented with toxic epidermal necrolysis.", + "The patient's toxic epidermal necrolysis was initially diagnosed as a scald burn.", + "Further anamnesis was prompted by spread of the lesions during hospitalization.", + "The patient had been receiving ceftriaxone for several days.", + "To the best of our knowledge, this is the first case of ceftriaxone-induced toxic epidermal necrolysis in the English literature." + ] + }, + { + "id": "multiclinsum_test_2495_en.txt", + "fulltext": "A 41-year-old Caucasian woman referred 6 months of bilateral blurred vision, more intense when she woke up. She had undergone surgery for implantation of cosmetic NewColorIris devices in both eyes 15 years before, without any complication or ocular trauma during that time .\nOcular examination confirmed low hyperopia (+ 0.75 D) in both eyes and she did not wear contact lenses (CL). Her best-corrected visual acuity was 20/20 in both eyes. The slit lamp examination showed bilateral and symmetric slight corneal edema with early decompensation, epithelial bullae and presence of pigment in the endothelium (specular microscopy showed a low endothelial cell count in the right eye (1268 cells/mm2), as well as in the left one (1122 cells/mm2). Silicone cosmetic implants in front of the iris were also observed in the AC with a central hole of 3.4 mm that did not match the pupillary axis in the right eye . Although iris evaluation was limited due to those implants, iris atrophy was observed by backlighting.\nThe position of both iris implants was assessed in detail by the means of anterior segment optical coherence tomography (AS-OCT, CASIA2, Tomey Corporation, Nagoya, Japan), and decentration was measured with several scans . The decentration of the iris implant from the pupillary axis in the right eye was 475 μm to the temporal sector and 238 μm superiorly . The iris implant in the left eye was more centered: it had moved 308 μm superiorly but only 15 μm to the temporal quadrant .\nIOP measurements obtained with Goldmann applanation tonometry were 28 mmHg and 18 mmHg in the right eye and in the left eye, respectively. Central corneal thickness was 588 μm in the right eye and 559 μm in the left eye.\nGonioscopy (performed with a Posner gonioprism) demonstrated a tendency to angle closure in both eyes (grade II in the superior, inferior and temporal quadrants and 0 in the nasal quadrant, according to Shaffer’s grading system to assess angle opening), with a large amount of pigment at the angle, more increased at VI o’clock . Those findings were also identified by the means of the iris-trabecular contact (ITC) analysis provided by AS-OCT: the ITC index was 18.3% in the right eye and 13.3% in the left eye, with nasal areas of possible peripheral anterior synechiae (PAS) in both eyes .\nFundal examination revealed no pathological findings and the optic discs were normal, with a cup-to-disc ratio of 0.4 in both eyes. Humphrey computerized perimetry performed with SITA standard 24–2 strategy (Carl Zeiss Meditec, Dublin, CA, USA) showed no perimetric defects in either eye. The retinal nerve fiber layer thickness measured by OCT (Triton, Topcon Corporation, Tokyo, Japan) was within the normal limits in both eyes.\nBased on all these results, the most likely diagnosis was bilateral corneal decompensation, as well as ocular hypertension (OHT) in the right eye, due to secondary pigment dispersion syndrome. Beta-blockers eyedrops were prescribed for her right eye, and the surgical removal of both cosmetic implants was considered as a further management option. The patient did not attend the scheduled follow-up visits.", + "fulltext_subclaims": [ + "The patient is a 41-year-old Caucasian woman.", + "She reported 6 months of bilateral blurred vision, more intense when she woke up.", + "She had undergone surgery for implantation of cosmetic NewColorIris devices in both eyes 15 years before.", + "There were no complications or ocular trauma during the 15 years after the surgery.", + "Ocular examination confirmed low hyperopia (+ 0.75 D) in both eyes.", + "She did not wear contact lenses.", + "Her best-corrected visual acuity was 20/20 in both eyes.", + "The slit lamp examination showed bilateral and symmetric slight corneal edema with early decompensation.", + "Epithelial bullae were observed.", + "Pigment was present in the endothelium.", + "Specular microscopy showed a low endothelial cell count in the right eye (1268 cells/mm2).", + "Specular microscopy showed a low endothelial cell count in the left eye (1122 cells/mm2).", + "Silicone cosmetic implants in front of the iris were observed in the anterior chamber.", + "The central hole of the implant in the right eye did not match the pupillary axis.", + "The decentration of the iris implant from the pupillary axis in the right eye was 475 μm to the temporal sector.", + "The decentration of the iris implant from the pupillary axis in the right eye was 238 μm superiorly.", + "The iris implant in the left eye had moved 308 μm superiorly.", + "The iris implant in the left eye had moved 15 μm to the temporal quadrant.", + "IOP measurements obtained with Goldmann applanation tonometry were 28 mmHg in the right eye.", + "IOP measurements obtained with Goldmann applanation tonometry were 18 mmHg in the left eye.", + "Central corneal thickness was 588 μm in the right eye.", + "Central corneal thickness was 559 μm in the left eye.", + "Gonioscopy demonstrated a tendency to angle closure in both eyes.", + "The ITC index was 18.3% in the right eye.", + "The ITC index was 13.3% in the left eye.", + "Nasal areas of possible peripheral anterior synechiae were identified in both eyes.", + "Fundal examination revealed no pathological findings.", + "The optic discs were normal, with a cup-to-disc ratio of 0.4 in both eyes.", + "Humphrey computerized perimetry showed no perimetric defects in either eye.", + "The retinal nerve fiber layer thickness measured by OCT was within the normal limits in both eyes.", + "The most likely diagnosis was bilateral corneal decompensation.", + "The most likely diagnosis was ocular hypertension in the right eye due to secondary pigment dispersion syndrome.", + "Beta-blockers eyedrops were prescribed for her right eye.", + "The surgical removal of both cosmetic implants was considered as a further management option.", + "The patient did not attend the scheduled follow-up visits." + ], + "summary": "A 41-year-old Caucasian woman presented with blurred vision in both eyes over the last 6 months. Fifteen years earlier, she had undergone bilateral implantation of additive iris implants for aesthetic purposes, without any complication or ocular trauma during the follow-up. Ocular examination showed bilateral mild corneal edema, iris atrophy, and presence of pigment in the endothelium. Increased IOP (28 mmHg) was identified in the right eye. Anterior segment optical coherence tomography (AS-OCT) confirmed the decentration of the iris implant from the pupillary axis in that eye. Gonioscopy demonstrated pigment dispersion in both eyes, as well as a tendency to bilateral angle closure, that was also illustrated by AS-OCT analysis. Endothelial cell count was 1268 cells/mm2 in the right eye and 1122 cells/mm2 in the left eye. The presence of both implants was affecting corneal endothelium and anterior chamber angle in both eyes, and additionally, the decentration of the device in the case of the right eye led to secondary ocular hypertension in that eye.", + "summary_subclaims": [ + "The patient is a 41-year-old Caucasian woman.", + "She presented with blurred vision in both eyes over the last 6 months.", + "Fifteen years earlier, she had undergone bilateral implantation of additive iris implants for aesthetic purposes.", + "There was no complication or ocular trauma during the follow-up.", + "Ocular examination showed bilateral mild corneal edema.", + "Ocular examination showed iris atrophy.", + "Ocular examination showed presence of pigment in the endothelium.", + "Increased IOP of 28 mmHg was identified in the right eye.", + "Anterior segment optical coherence tomography confirmed the decentration of the iris implant from the pupillary axis in the right eye.", + "Gonioscopy demonstrated pigment dispersion in both eyes.", + "Gonioscopy demonstrated a tendency to bilateral angle closure.", + "The AS-OCT analysis illustrated the tendency to bilateral angle closure.", + "The endothelial cell count was 1268 cells/mm2 in the right eye.", + "The endothelial cell count was 1122 cells/mm2 in the left eye.", + "The presence of both implants was affecting corneal endothelium and anterior chamber angle in both eyes.", + "The decentration of the device in the right eye led to secondary ocular hypertension in that eye." + ] + }, + { + "id": "multiclinsum_test_2248_en.txt", + "fulltext": "On January 8, 2019, a 28-year-old primigravid woman at 27th wk of gestation was admitted to our hospital with edema of both lower limbs for 4 d, elevated blood pressure (150/98 mmHg) and proteinuria (4+) for 1 d.\nExamination results on the tenth week of gestation showed blood pressure of 110/60 mmHg, negative urine protein and a platelet count of 234 × 109/L. Antenatal checkup was conducted regularly and showed normal outcomes except for edema in both limbs, hypertension and proteinuria before admission.\nThere was no history of past illness.\nShe was married without the history of pregnancy or contraception. Her spouse was healthy and her family history was unremarkable.\nPhysical examination revealed that her blood pressure was 141/90 mmHg, temperature was 36.5 °C, pulse rate was 92 bpm and respiratory rate was 18 breaths/min. The uterine height was 24 cm and abdominal circumference was 96 cm. Fetal weight was estimated to be 800 g.\nOn the 1st day of admission, routine blood examination showed a white blood cell count of 8.43 × 109/L, red blood cell count of 3.37 × 1012/L and platelet count of 86 × 109/L. An examination of blood coagulation function showed a D-dimer level of 1309 ng/mL (fibrinogen equivalent units). Liver and renal function examinations showed decreased albumin (33 g/L) and increased lactate dehydrogenase (345 U/L), urea nitrogen (9.1 mmol/L) and uric acid (539 μmol/L) with normal levels of alanine transaminase (17 U/L) and aspartate aminotransferase (32 U/L).\nColor Doppler ultrasound examination at admission showed a second trimester pregnancy equivalent to 26 wk of gestation as well as normal fetal movement and a fetal heart rate of 160 bpm. The fetal head was located at the uterine fundus. The placenta of Grade I was in the anterior uterine wall. The fetal weight was estimated as 790 g and conditions of the fetus growth were as following: biparietal diameter: 6.6 cm; femur length: 4.6cm; humeral length: 4.5 cm; head circumference: 24.8 cm; and abdominal circumference: 20.1 cm. Systolic/diastolic ratio of the umbilical artery and the fetal middle cerebral artery was 3.10 and 3.30, respectively. The amniotic fluid index was 12.9 cm.", + "fulltext_subclaims": [ + "The patient was a 28-year-old primigravid woman.", + "She was admitted at 27th wk of gestation.", + "She had edema of both lower limbs for 4 d.", + "She had elevated blood pressure (150/98 mmHg).", + "She had proteinuria (4+) for 1 d.", + "Examination results on the tenth week of gestation showed blood pressure of 110/60 mmHg.", + "Urine protein was negative on the tenth week of gestation.", + "Platelet count was 234 × 109/L on the tenth week of gestation.", + "Antenatal checkup was conducted regularly.", + "Antenatal checkup showed normal outcomes except for edema in both limbs.", + "There was no history of past illness.", + "She was married without the history of pregnancy or contraception.", + "Her spouse was healthy.", + "Her family history was unremarkable.", + "Physical examination revealed blood pressure of 141/90 mmHg.", + "Physical examination revealed temperature of 36.5 °C.", + "Physical examination revealed pulse rate of 92 bpm.", + "Physical examination revealed respiratory rate of 18 breaths/min.", + "The uterine height was 24 cm.", + "The abdominal circumference was 96 cm.", + "Fetal weight was estimated to be 800 g.", + "Routine blood examination showed a white blood cell count of 8.43 × 109/L.", + "Routine blood examination showed a red blood cell count of 3.37 × 1012/L.", + "Routine blood examination showed a platelet count of 86 × 109/L.", + "D-dimer level was 1309 ng/mL (fibrinogen equivalent units).", + "Albumin was 33 g/L.", + "Lactate dehydrogenase was 345 U/L.", + "Urea nitrogen was 9.1 mmol/L.", + "Uric acid was 539 μmol/L.", + "Color Doppler ultrasound showed a second trimester pregnancy equivalent to 26 wk of gestation.", + "Fetal heart rate was 160 bpm.", + "The fetal head was located at the uterine fundus.", + "The placenta of Grade I was in the anterior uterine wall.", + "Fetal weight was estimated as 790 g.", + "Biparietal diameter was 6.6 cm.", + "Femur length was 4.6 cm.", + "Humeral length was 4.5 cm.", + "Head circumference was 24.8 cm.", + "Abdominal circumference was 20.1 cm.", + "Systolic/diastolic ratio of the umbilical artery was 3.10.", + "Systolic/diastolic ratio of the fetal middle cerebral artery was 3.30.", + "The amniotic fluid index was 12.9 cm." + ], + "summary": "A 28-year-old primigravid woman was admitted to our hospital in the 27th wk of gestation with the primary diagnosis of severe pre-eclampsia. Although spasmolysis and antihypertensive therapy were administered since admission, the 24-h proteinuria of the 2nd day after admission reached 10311.0 mg. In the 47th h of admission, immunologic examinations revealed increased levels of anti-double stranded DNA antibody, anti-nuclear antibody, anti-cardiolipin antibody, anti-Sjögren's syndrome-related antigen A antibody and anti-nucleosome antibody and decreased levels of complement C3 and C4. One hour later, ultrasonography of the lower limbs showed thrombus of the bilateral popliteal veins. The diagnosis of SLE and antiphospholipid syndrome was indicated. In the 54th h, the patient manifested with convulsion, dyspnea and blurred vision. Ten hours later, intrauterine death was revealed by ultrasonography. Emergent surgery consisting of inferior vena cava filter implantation and subsequent cesarean section was performed. Following glucocorticoid and anticoagulation therapy after delivery, the patient had an optimal response with improvements in symptoms and immunological markers.", + "summary_subclaims": [ + "The patient was a 28-year-old primigravid woman.", + "She was admitted in the 27th wk of gestation.", + "The primary diagnosis was severe pre-eclampsia.", + "Spasmolysis and antihypertensive therapy were administered since admission.", + "The 24-h proteinuria of the 2nd day after admission reached 10311.0 mg.", + "Immunologic examinations were performed in the 47th h of admission.", + "Anti-double stranded DNA antibody levels were increased.", + "Anti-nuclear antibody levels were increased.", + "Anti-cardiolipin antibody levels were increased.", + "Anti-Sjögren's syndrome-related antigen A antibody levels were increased.", + "Anti-nucleosome antibody levels were increased.", + "Complement C3 levels were decreased.", + "Complement C4 levels were decreased.", + "Ultrasonography of the lower limbs showed thrombus of the bilateral popliteal veins.", + "The diagnosis of SLE and antiphospholipid syndrome was indicated.", + "The patient manifested with convulsion, dyspnea and blurred vision in the 54th h.", + "Intrauterine death was revealed by ultrasonography ten hours after the manifestation.", + "Emergent surgery consisting of inferior vena cava filter implantation and subsequent cesarean section was performed.", + "Following glucocorticoid and anticoagulation therapy after delivery, the patient had an optimal response.", + "The patient had improvements in symptoms and immunological markers." + ] + }, + { + "id": "multiclinsum_test_2995_en.txt", + "fulltext": "A 41-year-old man presented to our outpatient department with intermittent discharge of a turbid fluid (<1 mL) from his scrotum. On physical examination, a pinhole was noted over his left scrotum with squeezing pain and discharge. Infectious sinusitis or a fistula was impressed initially. An anal fistula was ruled out by digital rectal examination, and a urethra-cutaneous fistula was also excluded by cystourethroscopy. However, the cystourethroscopy examination revealed that there was no left ureteral orifice.\nComputed tomography revealed agenesis of his left kidney and a cystic lesion over his left scrotum . Because of a recurrent local heat sensation, turbid discharge, tenderness, and infection, he underwent resection of the infectious sinus . During surgery, the wound was deepened along with the sinus to the retropubic bone. Near the tail of the sinus, a connection was noted to a channel-like structure. For further investigation, patient was placed at supine position, and mobile C-arm X-ray system was setting for image study. Contrast medium was injected and revealed a channel-like structure about 15 cm in length with a blind end in an upward direction . The setting of mobile C-arm X-ray system is conversely, so the picture showed mirror image. The direction of this tubule was compatible with the development of the left ureter. The tube was ligated and the cut end was sent for surgical pathology. The specimen is confirmed as ureter histologically .", + "fulltext_subclaims": [ + "A 41-year-old man presented with intermittent discharge of a turbid fluid (<1 mL) from his scrotum.", + "On physical examination, a pinhole was noted over his left scrotum with squeezing pain and discharge.", + "Infectious sinusitis or a fistula was impressed initially.", + "An anal fistula was ruled out by digital rectal examination.", + "A urethra-cutaneous fistula was also excluded by cystourethroscopy.", + "The cystourethroscopy examination revealed that there was no left ureteral orifice.", + "Computed tomography revealed agenesis of his left kidney.", + "Computed tomography revealed a cystic lesion over his left scrotum.", + "Because of a recurrent local heat sensation, turbid discharge, tenderness, and infection, he underwent resection of the infectious sinus.", + "During surgery, the wound was deepened along with the sinus to the retropubic bone.", + "Near the tail of the sinus, a connection was noted to a channel-like structure.", + "Contrast medium was injected and revealed a channel-like structure about 15 cm in length with a blind end in an upward direction.", + "The setting of mobile C-arm X-ray system is conversely, so the picture showed mirror image.", + "The direction of this tubule was compatible with the development of the left ureter.", + "The tube was ligated and the cut end was sent for surgical pathology.", + "The specimen is confirmed as ureter histologically." + ], + "summary": "A 41-year-old male presented with intermittent discharge of turbid fluid from his scrotum. A pinhole was noted in his left scrotum, and an infectious sinus or fistula was impressed. After serial studies, computed tomography revealed agenesis of his left kidney and a cystic lesion over his left scrotum. He underwent resection of the infectious sinus. Near the tail of the sinus, a connection was found to a channel-like structure. Contrast medium was injected which showed a blind end of this channel-like structure. The tube was ligated, and the cut end was sent for surgical pathology, which confirmed a left ureteric bud remnant.", + "summary_subclaims": [ + "The patient is a 41-year-old male.", + "He presented with intermittent discharge of turbid fluid from his scrotum.", + "A pinhole was noted in his left scrotum.", + "An infectious sinus or fistula was impressed.", + "Computed tomography revealed agenesis of his left kidney.", + "Computed tomography revealed a cystic lesion over his left scrotum.", + "He underwent resection of the infectious sinus.", + "Near the tail of the sinus, a connection was found to a channel-like structure.", + "Contrast medium was injected which showed a blind end of this channel-like structure.", + "The tube was ligated.", + "The cut end was sent for surgical pathology.", + "Surgical pathology confirmed a left ureteric bud remnant." + ] + }, + { + "id": "multiclinsum_test_1819_en.txt", + "fulltext": "A 32 weeks pregnant, 23-year-old known asthmatic woman presented to a peripheral hospital with acute respiratory failure during winter. Cold air was a known precipitant for her asthma. She was intubated and ventilated for presumed severe acute asthma with refractory bronchospasm. Following intubation she was found to be extremely difficult to ventilate and was retrieved to our intensive care unit for further management.\nShe had widespread, faint, prolonged monophonic wheeze on auscultation with no evidence of pneumothorax. Mechanical ventilation in volume control mode was commenced with an inspired oxygen fraction of 1.0, external Positive End Expiratory Pressure (PEEP) 0 cmH2O, respiratory rate six breaths per minute, a tidal volume of 300 ml, and inspiratory flow rate of 30 L/min. However, high peak airway pressures truncated each breath. Intrinsic PEEP was measured as 30 cmH2O, with evidence of dynamic hyperinflation and accompanying hemodynamic instability despite inspiratory to expiratory ratio of close to 1:16. An arterial blood gas sample revealed severe respiratory acidosis (pH of 6.92, PaO2 116 mmHg, and PaCO2 143 mmHg). There was evidence of foetal distress on Cardiotocograph (CTG). Bronchoscopy demonstrated a pedunculated tumour arising from the posterior tracheal wall, extending from the tip of the Endotracheal Tube (ET) and measuring approximately 4 cm by 2 cm. The tumour acted as a ball valve to cause severe expiratory airflow obstruction . The bronchoscope was advanced beyond the lesion and the ET advanced over the bronchoscope to bridge the lesion, resulting in dramatic improvements in lung mechanics and haemodynamics. Urgent Caesarean section was performed due to persistent decelerations on CTG, with birth of a healthy baby. Access to her previous records revealed that she previously presented with haemoptysis at 16 weeks of the current gestation. At this time she had a small polyp (~0.5 cm) in the same tracheal location, which had been excised and diagnosed as LCH.\nThe following day, tumour debulking was attempted. In view of the high risk of major haemorrhage and hypoxemia, precautionary cannulation for veno-venous Extra-Corporeal Membrane Oxygenation (ECMO) was established via a bi-femoral approach. Surgical debulking was complicated by significant haemorrhage causing desaturation (SpO2 < 80%). She was promptly commenced on ECMO with recovery of arterial oxygen saturation and minimal disruption to surgery. A small bolus of heparin (2000 units) was given intravenously just prior to connection of the ECMO circuit, but no further heparin was administered until after surgery. On return to the ICU, a low dose heparin infusion (10 units/kg/hour) was used to maintain ECMO circuit patency. The histopathology revealed recurrent LCH , with intact overlying epithelium (Arrow) and lobular arrangements (*) of proliferating capillaries (horizontal arrow) in an edematous fibro-myxoid stroma, containing extravasated red blood cells (vertical arrow). There was intense staining with CD31 Immunohistochemical staining highlighting proliferating endothelial cells and vascular origin of tumor. Her trachea was subsequently stented and ECMO was discontinued. She made a full recovery.", + "fulltext_subclaims": [ + "The patient was 32 weeks pregnant.", + "The patient was 23 years old.", + "The patient was known to have asthma.", + "She presented with acute respiratory failure.", + "Cold air was a known precipitant for her asthma.", + "She was intubated and ventilated for presumed severe acute asthma with refractory bronchospasm.", + "Following intubation, she was found to be extremely difficult to ventilate.", + "She was retrieved to the intensive care unit for further management.", + "She had widespread, faint, prolonged monophonic wheeze on auscultation.", + "There was no evidence of pneumothorax.", + "Mechanical ventilation in volume control mode was commenced.", + "The inspired oxygen fraction was 1.0.", + "External PEEP was 0 cmH2O.", + "The respiratory rate was six breaths per minute.", + "The tidal volume was 300 ml.", + "The inspiratory flow rate was 30 L/min.", + "High peak airway pressures truncated each breath.", + "Intrinsic PEEP was measured as 30 cmH2O.", + "There was evidence of dynamic hyperinflation.", + "There was hemodynamic instability.", + "The inspiratory to expiratory ratio was close to 1:16.", + "An arterial blood gas sample revealed a pH of 6.92.", + "The PaO2 was 116 mmHg.", + "The PaCO2 was 143 mmHg.", + "There was evidence of fetal distress on CTG.", + "Bronchoscopy demonstrated a pedunculated tumor arising from the posterior tracheal wall.", + "The tumor extended from the tip of the endotracheal tube.", + "The tumor measured approximately 4 cm by 2 cm.", + "The tumor acted as a ball valve causing severe expiratory airflow obstruction.", + "The bronchoscope was advanced beyond the lesion.", + "The endotracheal tube was advanced over the bronchoscope to bridge the lesion.", + "This resulted in dramatic improvements in lung mechanics.", + "This resulted in dramatic improvements in hemodynamics.", + "Urgent Caesarean section was performed due to persistent decelerations on CTG.", + "A healthy baby was born.", + "Access to her previous records revealed she had presented with hemoptysis at 16 weeks of the current gestation.", + "At 16 weeks, she had a small polyp (~0.5 cm) in the same tracheal location.", + "The polyp had been excised and diagnosed as LCH.", + "Tumor debulking was attempted the following day.", + "Precautionary cannulation for veno-venous ECMO was established via a bi-femoral approach.", + "Surgical debulking was complicated by significant hemorrhage causing desaturation (SpO2 < 80%).", + "She was promptly commenced on ECMO.", + "A small bolus of heparin (2000 units) was given intravenously just prior to connection of the ECMO circuit.", + "No further heparin was administered until after surgery.", + "On return to the ICU, a low dose heparin infusion (10 units/kg/hour) was used to maintain ECMO circuit patency.", + "The histopathology revealed recurrent LCH.", + "The histopathology showed intact overlying epithelium.", + "The histopathology showed lobular arrangements of proliferating capillaries.", + "The histopathology showed an edematous fibro-myxoid stroma.", + "The histopathology showed extravasated red blood cells.", + "There was intense staining with CD31 immunohistochemical staining.", + "CD31 highlighted proliferating endothelial cells.", + "The tumor was of vascular origin.", + "Her trachea was stented.", + "ECMO was discontinued.", + "She made a full recovery." + ], + "summary": "We describe a case of a 23-year-old known asthmatic who presented at 32 weeks gestation with life-threatening respiratory failure resembling acute severe asthma, requiring invasive ventilation which was extremely difficult. This was subsequently found to be due to a large tracheal LCH producing a ball-valve phenomenon and predominantly expiratory airflow limitation similar to acute asthma. The endotracheal tube was advanced past the lesion under bronchoscopic guidance, and urgent Caesarean section performed due to foetal distress. The tumour was subsequently debulked and the trachea stented, facilitated by bi-femoral veno-venous extra-corporeal membrane oxygenation with relatively low dose of heparin.", + "summary_subclaims": [ + "The patient was a 23-year-old known asthmatic.", + "She presented at 32 weeks gestation with life-threatening respiratory failure resembling acute severe asthma.", + "She required invasive ventilation which was extremely difficult.", + "The respiratory failure was due to a large tracheal LCH producing a ball-valve phenomenon.", + "The lesion caused predominantly expiratory airflow limitation similar to acute asthma.", + "The endotracheal tube was advanced past the lesion under bronchoscopic guidance.", + "An urgent Caesarean section was performed due to foetal distress.", + "The tumour was subsequently debulked.", + "The trachea was stented.", + "Bi-femoral veno-venous extra-corporeal membrane oxygenation was used.", + "A relatively low dose of heparin was used." + ] + }, + { + "id": "multiclinsum_test_518_en.txt", + "fulltext": "This is a case of a 14-year-old male who sustained a twisting injury to his right leg during early phase of COVID-19 pandemic. He sustained a three-part lateral triplane fracture of the ankle with a concomitant ipsilateral displaced spiral fracture of the shaft at middle-lower third junction of his right tibia . The mechanism of injury was a twisting injury with external rotation of the foot while running indoors. The ankle injury was initially missed in the emergency. The orthopedic team examined the patient the following morning and ordered a CT scan of the ankle on clinical and radiographic suspicion. CT ankle reported the triplane injury pattern . The coronal, sagittal cuts revealed 2 mm gap and axial cut revealed 3 mm gap at the articular surface without any step. Conservative plan of management was decided as the displacement of shaft fracture was <50%, varus/valgus angulation <5o, recurvatum <5 degrees and shortening <1 cm and triplane ankle fracture was without any intra-articular step. The patient underwent close reduction under fluoroscopy and above-knee casting and was discharged on day-2. Regular follow-ups were done at weekly intervals for initial 3 weeks post-discharge to check for any fracture displacement and then at 6, 10, 14, 18, and 22 weeks, 6 months, 9 months, and 1 year. Above-knee plaster cast was converted to a patellar tendon bearing (PTB) cast at the 10th week for another 4 weeks and weight-bearing was started on PTB cast. The shaft fracture showed abundant callus at 14 weeks and follow-up X-rays (, , , ). The triplane fracture was uniting well with no disruption of the tibial plafond and an initially open anterolateral physis of the distal tibial gradually closed in the follow-up X-rays. The patient achieved a good functional recovery in 22 weeks and there was no limb length discrepancy at the end of 1 year. Evaluation was done based on modified Weber scale using the pre-operative and post-operative scores for pain, walking, activity, and ankle, subtalar function and awarded clinical demerit points with scores 15/24 at 10 weeks, 10/24 at 14 weeks, 6/24 at 18 weeks, 4/24 at 22 weeks, 2/24 at 6 months, and 0/24 at 9 months.", + "fulltext_subclaims": [ + "The patient is a 14-year-old male.", + "He sustained a twisting injury to his right leg during early phase of the COVID-19 pandemic.", + "He sustained a three-part lateral triplane fracture of the ankle.", + "He had a concomitant ipsilateral displaced spiral fracture of the shaft at the middle-lower third junction of his right tibia.", + "The mechanism of injury was a twisting injury with external rotation of the foot while running indoors.", + "The ankle injury was initially missed in the emergency.", + "The orthopedic team ordered a CT scan of the ankle on clinical and radiographic suspicion.", + "CT ankle reported the triplane injury pattern.", + "The coronal, sagittal cuts revealed 2 mm gap at the articular surface.", + "The axial cut revealed 3 mm gap at the articular surface without any step.", + "The displacement of the shaft fracture was <50%.", + "The varus/valgus angulation was <5 degrees.", + "The recurvatum was <5 degrees.", + "The shortening was <1 cm.", + "The triplane ankle fracture was without any intra-articular step.", + "The patient underwent close reduction under fluoroscopy.", + "The patient was placed in an above-knee cast.", + "The patient was discharged on day-2.", + "Regular follow-ups were done at weekly intervals for initial 3 weeks post-discharge.", + "The above-knee plaster cast was converted to a patellar tendon bearing (PTB) cast at the 10th week.", + "The shaft fracture showed abundant callus at 14 weeks.", + "The triplane fracture was uniting well with no disruption of the tibial plafond.", + "The patient achieved a good functional recovery in 22 weeks.", + "There was no limb length discrepancy at the end of 1 year.", + "Evaluation was done based on modified Weber scale using pre-operative and post-operative scores.", + "The scores were 15/24 at 10 weeks.", + "The scores were 10/24 at 14 weeks.", + "The scores were 6/24 at 18 weeks.", + "The scores were 4/24 at 22 weeks.", + "The scores were 2/24 at 6 months.", + "The scores were 0/24 at 9 months." + ], + "summary": "This is a case of a 14-year-old male who sustained a twisting injury to his right leg during early phase of COVID-19 pandemic. He sustained a three-part lateral triplane fracture of the ankle with a concomitant displaced spiral fracture of the shaft of the right tibia. He underwent close reduction under fluoroscopy and above-knee casting for 10 weeks followed patellar tendon weight-bearing cast for 4 weeks. Both fractures healed uneventfully in 14 weeks with patient returning to full activities in 22 weeks.", + "summary_subclaims": [ + "The patient is a 14-year-old male.", + "He sustained a twisting injury to his right leg.", + "The injury occurred during the early phase of the COVID-19 pandemic.", + "He sustained a three-part lateral triplane fracture of the ankle.", + "He had a concomitant displaced spiral fracture of the shaft of the right tibia.", + "He underwent close reduction under fluoroscopy.", + "He was placed in an above-knee casting for 10 weeks.", + "He was then placed in a patellar tendon weight-bearing cast for 4 weeks.", + "Both fractures healed uneventfully in 14 weeks.", + "The patient returned to full activities in 22 weeks." + ] + }, + { + "id": "multiclinsum_test_2018_en.txt", + "fulltext": "An eighty-four year old man attended our accident and emergency department with a severe headache, runny nose and confusion. Detailed history taking was not initially possible at first, but with the arrival of the patient’s relatives, we were able to elucidate further details of his history. The patient’s illness had started two weeks ago with symptoms of sinusitis. He was diagnosed with an upper respiratory tract infection by his general practitioner, and treated with oral antibiotics. We were informed by the relatives that the patient had been “blowing his nose” with increasing frequency over the last two weeks and had not responded to the treatment given by his general practitioner. His rhinorrhoea got much worse, and he then developed a severe headache with worsening confusion over the 24 hours preceding admission. He had sustained severe craniofacial fractures 43 years ago after a serious fall.\nHe had undergone neurosurgery for this, but the precise details of the procedures performed were not clear although he had been left with a large scar on the right side of his forehead and an oculomotor nerve palsy. He had otherwise made an excellent recovery from this operation, and had a normal quality of life in full employment until retirement at the usual age. On examination, the patient was very confused. There have been no signs of recent trauma or head injury. Clinical examination revealed neck stiffness and photophobia. His white blood cell count (WBC) and C-reactive protein (CRP) slightly elevated. His chest radiograph was normal. Laboratory testing of the fluid from his nose confirmed it to be CSF; positive for glucose and beta 2-transferrin. The patient was confused and would not allow a lumbar puncture to be performed. Apart from confusion, system examination did not reveal any signs of focal neurological deficit.\nAn urgent CT head was performed which showed a pneumocranium and fractures of the frontal bone to the right side of the frontal sinus, involving the superior and medial orbital walls . It was initially thought that the patient had an acute head injury, but the absence of physical signs on examination made us question this diagnosis.\nUrgent neurosurgical advice was sought. The skull fractures were considered to be old injuries on review of the scans and a diagnosis of occult dural injury with endocranial complications was made.\nWe were advised to treat the patient conservatively with intravenous antibiotics and admission. He recovered rapidly and was discharged after three weeks with advice to avoid straining and maneuvers which could acutely raise intra-abdominal and intrathoracic pressure. He remains well on review 1 year later.", + "fulltext_subclaims": [ + "An eighty-four year old man attended our accident and emergency department with a severe headache, runny nose and confusion.", + "Detailed history taking was not initially possible at first.", + "The patient’s illness had started two weeks ago with symptoms of sinusitis.", + "He was diagnosed with an upper respiratory tract infection by his general practitioner.", + "He was treated with oral antibiotics.", + "The patient had been blowing his nose with increasing frequency over the last two weeks.", + "He had not responded to the treatment given by his general practitioner.", + "He then developed a severe headache with worsening confusion over the 24 hours preceding admission.", + "He had sustained severe craniofacial fractures 43 years ago after a serious fall.", + "He had undergone neurosurgery for this.", + "The precise details of the procedures performed were not clear.", + "He had a large scar on the right side of his forehead.", + "He had an oculomotor nerve palsy.", + "He had made an excellent recovery from this operation.", + "He had a normal quality of life in full employment until retirement at the usual age.", + "On examination, the patient was very confused.", + "There have been no signs of recent trauma or head injury.", + "Clinical examination revealed neck stiffness.", + "Clinical examination revealed photophobia.", + "His white blood cell count (WBC) and C-reactive protein (CRP) were slightly elevated.", + "His chest radiograph was normal.", + "Laboratory testing of the fluid from his nose confirmed it to be CSF.", + "The fluid was positive for glucose.", + "The fluid was positive for beta 2-transferrin.", + "The patient was confused and would not allow a lumbar puncture to be performed.", + "System examination did not reveal any signs of focal neurological deficit.", + "An urgent CT head was performed.", + "The CT showed a pneumocranium.", + "The CT showed fractures of the frontal bone to the right side of the frontal sinus.", + "The CT showed involvement of the superior and medial orbital walls.", + "It was initially thought that the patient had an acute head injury.", + "The absence of physical signs on examination made us question this diagnosis.", + "The skull fractures were considered to be old injuries on review of the scans.", + "A diagnosis of occult dural injury with endocranial complications was made.", + "We were advised to treat the patient conservatively with intravenous antibiotics.", + "He was advised to be admitted.", + "He recovered rapidly.", + "He was discharged after three weeks.", + "He was advised to avoid straining.", + "He was advised to avoid maneuvers which could acutely raise intra-abdominal and intrathoracic pressure.", + "He remains well on review 1 year later." + ], + "summary": "We present a case of occult dural injury with endocranial complications which occurred in a 34 year old man, with a history of head injury forty-three years ago. The patient presented with a triad of findings; meningitis, CSF rhinorrhoea and pneumocephalus. He was managed conservatively with intravenous antibiotics and observation and made a full recovery. The presence of acute endocranial symptoms and particularly these three findings in a patient with a previous history of head injury, no matter how long it had been should raise suspicion of the presence of an occult dural injury.", + "summary_subclaims": [ + "The patient was a 34 year old man.", + "The patient had a history of head injury forty-three years ago.", + "The patient presented with meningitis.", + "The patient presented with CSF rhinorrhoea.", + "The patient presented with pneumocephalus.", + "He was managed conservatively with intravenous antibiotics and observation.", + "He made a full recovery.", + "The presence of acute endocranial symptoms and particularly these three findings in a patient with a previous history of head injury, no matter how long it had been should raise suspicion of the presence of an occult dural injury." + ] + }, + { + "id": "multiclinsum_test_1126_en.txt", + "fulltext": "A previously healthy 14-year-old girl presented with cough, sputum and shortness of breath after activity. She had a history of trauma 10 days prior to presentation. She was previously admitted to another hospital and diagnosed with tuberculosis. Antituberculosis treatment was ineffective; therefore, she was transferred to our hospital. She had no family history of genetic or osteolytic disease. She was admitted to the respiratory department with dyspnea and persistent cough. Examination revealed tachypnea, diminished breathing sounds, a deformity on her back, and tenderness. She exhibited percussion pain in the T6–T9 vertebrae and an absence of motor power in the thoracic spine. Neurological examination was normal.\nPlain radiographs revealed an osteolytic lesion in the thoracic spine . Thoracic computed tomography (CT) showed a moderate right-sided pleural effusion and atelectasis . Her thoracic spine CT revealed the presence of ill-defined lytic lesions in the ribs and the T6–T9 vertebrae as well as a fracture in the T7 vertebra . Magnetic resonance imaging (MRI) scans revealed a pathological fracture and spinal canal stenosis at the T7 vertebra and high intensity in the T6–T9 vertebral bodies . Whole-body bone scintigraphy was performed, and radiolucent foci were observed in the fracture lesion on the radiographic images. Blood analyses indicated nearly normal biochemical levels, except for a high concentration of cross-linked N-terminal telopeptides of type I collagen (111.60 ng/ml) and decreased vitamin D (8.99 ng/ml).\nRecurrent chylothorax was managed via repeated thoracentesis, and percutaneous fine needle aspiration of the lesion yielded more than 1000 ml/day of a reddish turbid, nonodorous fluid. Analysis of the aspirate revealed a positive Rivalta test result, which was reported as chylothorax. The patient was transferred to the thoracic surgery department to control the pleural effusion. A thoracic duct ligation and pleurodesis along with chest drainage was planned. The biopsy could not be analyzed because insufficient tissue was taken from the lesion during the process. Chest CT showed bilateral pleural effusions 2 days after surgery , and the chest was drained on the left side. To investigate the lesion pathology, the patient underwent another incisional biopsy of the T6–T9 vertebral bodies at the department of spine surgery. The bones appeared honeycomb-like intraoperatively. Postoperational pathological examination of the incisional biopsy revealed many dilated sinusoids with hemorrhaging, mononuclear and lymphocytic infiltration, fibrous tissue and dead bone . Based on the clinical, radiological and pathological findings, we confirmed the diagnosis of GSS because the biopsy material was negative for bacterial and fungal growth, and osteolysis was clearly demonstrated in the imaging results.\nNo treatment has been approved for GSS; thus, several treatment methods are used. In our case, the treatment plan was discussed and confirmed in a multidisciplinary clinic meeting. Bisphosphonates and vitamin D therapy were administered to treat the disease because the patient was vitamin D deficient, and the disease is self-limiting. Because the neurological exam showed no abnormalities, conservative treatment was considered, and a custom-made polypropylene body jacket was prescribed to prevent kyphotic deformity. Her clinical status improved steadily following the oral bisphosphonates and vitamin D supplementation. A final thoracic CT was performed 2 years after diagnosis and showed a successful reduction in the amount of pleural fluid and stabilization of the thoracic spine deformity.", + "fulltext_subclaims": [ + "The patient is a 14-year-old girl.", + "She had a history of trauma 10 days prior to presentation.", + "She was previously admitted to another hospital and diagnosed with tuberculosis.", + "Antituberculosis treatment was ineffective.", + "She was transferred to our hospital.", + "She had no family history of genetic or osteolytic disease.", + "She was admitted to the respiratory department with dyspnea and persistent cough.", + "Examination revealed tachypnea.", + "Examination revealed diminished breathing sounds.", + "Examination revealed a deformity on her back.", + "Examination revealed tenderness.", + "She exhibited percussion pain in the T6–T9 vertebrae.", + "She exhibited an absence of motor power in the thoracic spine.", + "Neurological examination was normal.", + "Plain radiographs revealed an osteolytic lesion in the thoracic spine.", + "Thoracic CT showed a moderate right-sided pleural effusion.", + "Thoracic CT showed atelectasis.", + "Thoracic spine CT revealed ill-defined lytic lesions in the ribs and the T6–T9 vertebrae.", + "Thoracic spine CT revealed a fracture in the T7 vertebra.", + "MRI scans revealed a pathological fracture and spinal canal stenosis at the T7 vertebra.", + "MRI scans revealed high intensity in the T6–T9 vertebral bodies.", + "Whole-body bone scintigraphy was performed.", + "Radiolucent foci were observed in the fracture lesion on the radiographic images.", + "Blood analyses indicated nearly normal biochemical levels.", + "Blood analyses indicated a high concentration of cross-linked N-terminal telopeptides of type I collagen (111.60 ng/ml).", + "Blood analyses indicated decreased vitamin D (8.99 ng/ml).", + "Recurrent chylothorax was managed via repeated thoracentesis.", + "Percutaneous fine needle aspiration of the lesion yielded more than 1000 ml/day of a reddish turbid, nonodorous fluid.", + "Analysis of the aspirate revealed a positive Rivalta test result.", + "The patient was transferred to the thoracic surgery department to control the pleural effusion.", + "A thoracic duct ligation and pleurodesis along with chest drainage was planned.", + "The biopsy could not be analyzed because insufficient tissue was taken from the lesion during the process.", + "Chest CT showed bilateral pleural effusions 2 days after surgery.", + "The chest was drained on the left side.", + "The patient underwent another incisional biopsy of the T6–T9 vertebral bodies at the department of spine surgery.", + "The bones appeared honeycomb-like intraoperatively.", + "Postoperational pathological examination of the incisional biopsy revealed many dilated sinusoids with hemorrhaging.", + "Postoperational pathological examination of the incisional biopsy revealed mononuclear and lymphocytic infiltration.", + "Postoperational pathological examination of the incisional biopsy revealed fibrous tissue.", + "Postoperational pathological examination of the incisional biopsy revealed dead bone.", + "Based on the clinical, radiological and pathological findings, we confirmed the diagnosis of GSS.", + "The biopsy material was negative for bacterial and fungal growth.", + "Osteolysis was clearly demonstrated in the imaging results.", + "No treatment has been approved for GSS.", + "Bisphosphonates and vitamin D therapy were administered to treat the disease.", + "The patient was vitamin D deficient.", + "The disease is self-limiting.", + "Conservative treatment was considered.", + "A custom-made polypropylene body jacket was prescribed to prevent kyphotic deformity.", + "Her clinical status improved steadily following the oral bisphosphonates and vitamin D supplementation.", + "A final thoracic CT was performed 2 years after diagnosis.", + "The final thoracic CT showed a successful reduction in the amount of pleural fluid.", + "The final thoracic CT showed stabilization of the thoracic spine deformity." + ], + "summary": "A 14-year-old patient presented with GSS affecting the thoracic spine with bilateral chylothorax. The case was successfully managed using combined conservative and surgical treatments. At the 2-year follow-up visit, the amount of pleural fluid was reduced, the patient's respiratory function had improved, and the deformity on the thoracic spine had gradually stabilized.", + "summary_subclaims": [ + "The patient is a 14-year-old.", + "The patient had GSS affecting the thoracic spine.", + "The patient had bilateral chylothorax.", + "The case was managed using combined conservative and surgical treatments.", + "At the 2-year follow-up visit, the amount of pleural fluid was reduced.", + "At the 2-year follow-up visit, the patient's respiratory function had improved.", + "At the 2-year follow-up visit, the deformity on the thoracic spine had gradually stabilized." + ] + }, + { + "id": "multiclinsum_test_500_en.txt", + "fulltext": "A 67-year-old woman was admitted to our department for the treatment of right empyema. She had been complaining of fever and fatigue about 7 weeks ago and had been treated with antibiotics by her primary care physician. However, as her symptoms did not improve, computed tomography (CT) was performed. A chest drainage tube was inserted because the chest CT showed pleural effusion with pleural thickening in the right thoracic cavity. She was diagnosed with empyema because bacteria were detected in cloudy fluid from the thoracic drainage tube. Blood and biochemical findings at admission showed an elevated inflammatory response (white blood cell 11520/μL and C-reactive protein 11.19 mg/dL). Chest X-ray showed remaining pleural effusion and insufficient expansion of the lung, although a drainage tube had been inserted in the right thoracic cavity . Chest CT showed fluid collection in three independent spaces within the right thoracic cavity. The first empyema cavity was from the ventral side of the superior vena cava in the anterior mediastinum to the inferior pulmonary vein along the pericardium (cavity I: Fig. a–c). The second empyema cavity was present from outside of the right upper lobe to the interlobar space between upper and lower lobes, in which a chest drainage tube has been inserted (cavity II: Fig. a–c). The third empyema cavity was located from the outside of the right lower lobe to the diaphragm (cavity III: Fig. a–c). It was assumed that a firm adhesion between the lung and chest wall was developed because a long time had passed since the onset. Therefore, we decided to use CBCT to completely debride three empyema cavities separately by VATS.\nUnder general anesthesia, the patient is placed in the lateral decubitus position. A careful check is made if the C-arm of the CBCT can be adequately rotated around the operation table. We can obtain scanning images of 18.5 cm in longer axis (craniocaudal direction) by a single rotation of the C-arm, and the single rotation needs 6 s (6 s acquisition protocol (6s DynaCT Body)). The field of view of the scanned image (24 × 24 cm, DynaCT mode) provided by CBCT is smaller than that of the multidetector computed tomography (MDCT). Thus, two rotations of the C-arm are needed to obtain images of the hemithorax. Scanning was performed under inflation of the lungs with 20 cm H2O airway pressure. The amount of irradiation dose in one rotation was 60 to 70 mGy. We took the images before and after the surgical procedure in order to determine the site of skin incision and to confirm the presence or absence of an overlooked empyema cavity. Cavity I was only in a narrow range with the chest wall, and it was located on the back of cost rib cartilage. By clicking any intended anatomical structures on CBCT images, the position was readily depicted by lase projection on the body surface, which helped to place the best skin incision . In cavity II, CBCT after initial debridement showed insufficiently dissected cavity . Additional debridement resulted in successful shrinkage of the empyema cavity . For cavity III, the usual debridement by VATS was possible without using CBCT. This patient had three isolated empyema cavities requiring chest drainage tube insertion into the individual cavities followed by VATS debridement using cupped forceps. The operation time was 315 min and the amount of bleeding was 225 g. A total of only three small incisions was made in this patient for adequate debridement of the three cavities . The patient recovered uneventfully without additional interventional therapy. Chest X-ray before discharge showed a slight shadow due to atelectasis, but well expansion of the other part of the lung .\nCBCT in the hybrid operating room is currently used in various fields, such as cardiology, neurosurgery, and vascular surgery. With regard to respiratory surgery, although some reports describe the usefulness in identifying the intrapulmonary small lesions , it remains controversial if CBCT is useful in surgical treatment of empyema. Decortication via open thoracotomy requires wide adehesiolysis in order to peel the fibrous capsule of each cavity via single thoracotomy incision, which can often result in lung injury, thereby development of bronchopleural fistulae. Therefore, for some patients who have multiple isolated empyema cavities by developing firm intrathoracic adhesion, it is better performing debridement and drainage, individually. For these cases, VATS is advantageous because it does not necessarily require adhesiolysis and wide skin incision. However, concern remains whether the debridement without intrathoracic adhesiolysis is adequate or not because of the possibility of residual or overlooked contaminated cavities. Although transthoracic echo may also be useful to identify the location of the empyema cavity, this modality is not helpful to know whether the debridement is adequately accomplished or not. If the debridement was incomplete as a result of worrying about an accidental injury of the surrounding organ, additional interventions may be required due to the persistent empyema cavity or insufficient expansion of the ipsilateral lung [, ]. In the present case, accurate and effective VATS debridement and drainage with small skin incision was accomplished by using CBCT.\nWith respect to the radiation exposure, Chao et al. reported based on their experience with preoperative or intraoperative localization of small intrapulmonary nodules. They reported that the amount of radiation exposure by intraoperative localization with CBCT was comparable to that by preoperative localization with MDCT . Because the amount of exposure by CBCT may depend on the times of C-arm rotation, we must attempt to restrict the times and extent of radiation exposure by CBCT.", + "fulltext_subclaims": [ + "The patient was a 67-year-old woman.", + "She was admitted for the treatment of right empyema.", + "She had been complaining of fever and fatigue about 7 weeks ago.", + "She had been treated with antibiotics by her primary care physician.", + "Computed tomography (CT) was performed.", + "A chest drainage tube was inserted.", + "Chest CT showed pleural effusion with pleural thickening in the right thoracic cavity.", + "Bacteria were detected in cloudy fluid from the thoracic drainage tube.", + "She was diagnosed with empyema.", + "Blood findings showed an elevated white blood cell count of 11520/μL.", + "Chest X-ray showed remaining pleural effusion.", + "Chest CT showed fluid collection in three independent spaces within the right thoracic cavity.", + "The first empyema cavity was from the ventral side of the superior vena cava in the anterior mediastinum to the inferior pulmonary vein along the pericardium.", + "The second empyema cavity was present from outside of the right upper lobe to the interlobar space between upper and lower lobes.", + "The third empyema cavity was located from the outside of the right lower lobe to the diaphragm.", + "It was assumed that a firm adhesion between the lung and chest wall was developed.", + "We decided to use CBCT to completely debride three empyema cavities separately by VATS.", + "The patient is placed in the lateral decubitus position.", + "A single rotation of the C-arm provides scanning images of 18.5 cm in longer axis.", + "The single rotation needs 6 s.", + "The field of view of the scanned image provided by CBCT is smaller than that of MDCT.", + "Two rotations of the C-arm are needed to obtain images of the hemithorax.", + "Scanning was performed under inflation of the lungs with 20 cm H2O airway pressure.", + "The amount of irradiation dose in one rotation was 60 to 70 mGy.", + "Images were taken before and after the surgical procedure.", + "Cavity I was only in a narrow range with the chest wall.", + "Cavity I was located on the back of cost rib cartilage.", + "CBCT after initial debridement showed insufficiently dissected cavity.", + "Additional debridement resulted in successful shrinkage of the empyema cavity.", + "For cavity III, the usual debridement by VATS was possible without using CBCT.", + "The operation time was 315 min.", + "The amount of bleeding was 225 g.", + "A total of only three small incisions was made.", + "The patient recovered uneventfully.", + "Chest X-ray before discharge showed a slight shadow due to atelectasis.", + "CBCT in the hybrid operating room is currently used in various fields.", + "Decortication via open thoracotomy requires wide adhesiolysis.", + "Decortication via open thoracotomy can often result in lung injury.", + "Decortication via open thoracotomy can result in development of bronchopleural fistulae.", + "For some patients with multiple isolated empyema cavities, it is better performing debridement and drainage individually.", + "VATS is advantageous because it does not necessarily require adhesiolysis.", + "Concern remains whether the debridement without intrathoracic adhesiolysis is adequate.", + "Transthoracic echo may be useful to identify the location of the empyema cavity.", + "Transthoracic echo is not helpful to know whether the debridement is adequately accomplished.", + "In the present case, accurate and effective VATS debridement and drainage with small skin incision was accomplished by using CBCT.", + "The amount of radiation exposure by intraoperative localization with CBCT was comparable to that by preoperative localization with MDCT." + ], + "summary": "A 67-year-old woman was admitted to our department for the treatment of right empyema. Chest computed tomography showed fluid collection in three independent spaces within the right thoracic cavity. It was assumed that a firm adhesion between the lung and chest wall was developed because about 7 weeks passed since the onset. Therefore, we decided to use CBCT to completely debride three empyema cavities separately by VATS. One cavity was only in a narrow range with the chest wall, and it was located on the back of cost rib cartilage. By clicking any intended anatomical structures on CBCT images, the position was readily depicted by lase projection on the body surface, which helped to place the best skin incision. Moreover, in other cavities, CBCT after initial debridement showed insufficiently dissected cavity. Additional debridement resulted in a successful shrinkage of the empyema cavity.", + "summary_subclaims": [ + "A 67-year-old woman was admitted to our department for the treatment of right empyema.", + "Chest computed tomography showed fluid collection in three independent spaces within the right thoracic cavity.", + "It was assumed that a firm adhesion between the lung and chest wall was developed because about 7 weeks passed since the onset.", + "We decided to use CBCT to completely debride three empyema cavities separately by VATS.", + "One cavity was only in a narrow range with the chest wall, and it was located on the back of cost rib cartilage.", + "By clicking any intended anatomical structures on CBCT images, the position was readily depicted by laser projection on the body surface.", + "CBCT after initial debridement showed insufficiently dissected cavity.", + "Additional debridement resulted in a successful shrinkage of the empyema cavity." + ] + }, + { + "id": "multiclinsum_test_1560_en.txt", + "fulltext": "A 21-year-old male with no past medical history presented to a rural ED with severe headache and decreased level of consciousness. He was brought by his friend, who stated the patient complained of a headache that began two hours prior to arrival while he was working at a local grocery store. En route, he acutely developed slurred speech and became unresponsive in the vehicle. There was no history of trauma, fevers, or illicit drug use.\nThe patient’s initial heart rate was 137 beats per minute (bpm), blood pressure 159/85 millimeters of mercury (mm Hg), and respiratory rate 17 breaths per minute, with a room-air oxygenation saturation of 100%. The patient was not following commands, but he opened his eyes to pain, and moved all extremities. He did not respond to verbal stimuli. His Glasgow Coma Scale was calculated to be eight. Corneal, gag, and cough reflexes were intact. Pupils were 3 millimeters and reactive bilaterally. Fundoscopic exam was not performed.\nThe patient was intubated on arrival for airway protection. Laboratory tests were unremarkable other than a lactic acidosis of 4.8 millimoles/liter (mmol/L) (reference range: 0.0–2.2 mmol/L), increasing to 7.8 mmol/L three hours later. Non-contrasted computed tomography (CT) of the head was obtained and recognized as hydrocephalus by the EP. No neurosurgical service was available at the ED, so the transfer process was initiated. The EP called the transfer centers of six hospitals with neurosurgical services across multiple states, none of which could accept the transfer.\nAfter CT, the patient developed decorticate posturing and was administered a bolus of 250 milliliters (mL) of 3% hypertonic saline, the head of his bed was raised to 30 degrees, propofol infusion was increased, and fentanyl infusion was added. The patient’s heart rate increased to 167 bpm, and blood pressure increased to 232/143 mm Hg with the right pupil dilated and unresponsive. A one gram per kilogram bolus of 20% mannitol and additional bolus 250 mL of 3% saline were administered.\nAfter multiple failed attempts at transfer, the EP called the unpublished number of the attending EP workstation at the institution where he had trained, and that institution eventually received the patient and requested assistance. Typically, transfers to the accepting facility are routed through a transfer call center, which contacts the attending physician for the specialty service, who discusses the case with the transferring physician and arranges further care. If the required higher level of service is unavailable, the transfer call center prevents the transfer without input from accepting services. In this case, the transferring EP was unable to communicate directly with the attending neurosurgeon because the neurological intensive care unit (ICU) was full, and the transfer call center followed established protocol and refused the transfer.\nThe receiving EP and the attending neurosurgeon discussed the time-sensitive, life-threatening nature of the case and the difficulties in transfer. The neurosurgeon accepted the patient to the ED and began treatment there. A neurosurgery resident and a neurologic ICU nurse were made available to treat the patient in the ED while preparations were made to find a neurologic ICU bed. The patient was flown by helicopter to the accepting facility.\nEmergent bedside bilateral external ventricular drains (EVD) were placed on arrival to the accepting ED. Magnetic resonance imaging of the head revealed a colloid cyst obstructing the bilateral foramen of Monro, resulting in hydrocephalus . The cyst was resected via craniotomy. The patient was discharged with profound neurological disability after a prolonged inpatient stay to an inpatient rehabilitation facility. Five months after discharge, he followed commands, verbally responded to binary questions, fed himself, and stood with physical therapy assistance.", + "fulltext_subclaims": [ + "The patient was a 21-year-old male with no past medical history.", + "He presented to a rural ED with severe headache and decreased level of consciousness.", + "He was brought by his friend.", + "The patient's friend stated the headache began two hours prior to arrival.", + "The patient was working at a local grocery store when the headache began.", + "He acutely developed slurred speech and became unresponsive in the vehicle.", + "There was no history of trauma.", + "There was no history of fevers.", + "There was no history of illicit drug use.", + "The patient's initial heart rate was 137 bpm.", + "The patient's initial blood pressure was 159/85 mm Hg.", + "The patient's initial oxygen saturation was 100%.", + "The patient was not following commands.", + "The patient opened his eyes to pain.", + "The patient moved all extremities.", + "The patient did not respond to verbal stimuli.", + "The Glasgow Coma Scale was calculated to be eight.", + "Pupils were 3 millimeters and reactive bilaterally.", + "The patient was intubated on arrival for airway protection.", + "Laboratory tests were unremarkable other than a lactic acidosis of 4.8 mmol/L.", + "Non-contrasted CT of the head was obtained.", + "The CT was recognized as hydrocephalus by the EP.", + "No neurosurgical service was available at the ED.", + "The transfer process was initiated.", + "The EP called the transfer centers of six hospitals with neurosurgical services.", + "None of the six hospitals could accept the transfer.", + "After CT, the patient developed decorticate posturing.", + "A 250 mL bolus of 3% hypertonic saline was administered.", + "The head of the bed was raised to 30 degrees.", + "The propofol infusion was increased.", + "A fentanyl infusion was added.", + "The patient's heart rate increased to 167 bpm.", + "The patient's blood pressure increased to 232/143 mm Hg.", + "The right pupil was dilated and unresponsive.", + "A one gram per kilogram bolus of 20% mannitol was administered.", + "An additional 250 mL bolus of 3% saline was administered.", + "The EP called the unpublished number of the attending EP workstation at the institution where he had trained.", + "The accepting institution eventually received the patient.", + "Transfers to the accepting facility are typically routed through a transfer call center.", + "The transfer call center contacts the attending physician for the specialty service.", + "The attending physician discusses the case with the transferring physician.", + "The transfer call center prevents the transfer without input from accepting services.", + "The transferring EP was unable to communicate directly with the attending neurosurgeon.", + "The neurological ICU was full.", + "The transfer call center followed established protocol and refused the transfer.", + "The receiving EP and the attending neurosurgeon discussed the time-sensitive, life-threatening nature of the case.", + "The neurosurgeon accepted the patient to the ED.", + "A neurosurgery resident and a neurologic ICU nurse were made available to treat the patient in the ED.", + "The patient was flown by helicopter to the accepting facility.", + "Emergent bedside bilateral external ventricular drains were placed on arrival to the accepting ED.", + "MRI of the head revealed a colloid cyst obstructing the bilateral foramen of Monro.", + "The cyst was resected via craniotomy.", + "The patient was discharged with profound neurological disability.", + "The patient was discharged to an inpatient rehabilitation facility.", + "Five months after discharge, he followed commands.", + "Five months after discharge, he verbally responded to binary questions.", + "Five months after discharge, he fed himself.", + "Five months after discharge, he stood with physical therapy assistance." + ], + "summary": "We present the case of a previously healthy 21-year-old male with two hours of headache and rapid neurologic decompensation en route to and at the ED. Computed tomography revealed obstructive hydrocephalus recognized by the EP, who medically managed the increased intracranial pressure (ICP) and began the transfer process for neurosurgical evaluation and management. After refusal by six referral centers in multiple states, all of which were on diversion, the EP initiated an unorthodox transfer procedure to the institution at which he trained, ultimately transferring the patient by air. Bilateral external ventricular drains were placed in the receiving ED, and the patient ultimately underwent neurosurgical resection of an obstructive colloid cyst.", + "summary_subclaims": [ + "The patient is a previously healthy 21-year-old male.", + "The patient had two hours of headache.", + "The patient had rapid neurologic decompensation en route to and at the ED.", + "Computed tomography revealed obstructive hydrocephalus.", + "The EP medically managed the increased intracranial pressure.", + "The EP began the transfer process for neurosurgical evaluation and management.", + "Six referral centers in multiple states refused the transfer.", + "All six referral centers were on diversion.", + "The EP initiated an unorthodox transfer procedure to the institution at which he trained.", + "The patient was transferred by air.", + "Bilateral external ventricular drains were placed in the receiving ED.", + "The patient ultimately underwent neurosurgical resection of an obstructive colloid cyst." + ] + }, + { + "id": "multiclinsum_test_249_en.txt", + "fulltext": "In December 2000, a 49 year-old woman underwent left mastectomy for a stage IIA invasive ductal breast carcinoma with low proliferative activity (Ki 67 < 5%), negative hormone receptors and HER2 overexpressed (score 3+ at immunochemistry). In her medical history there were no cardiovascular comorbidities and she had no family history of cardiovascular disease.\nFrom February to July 2001 she received an adjuvant chemotherapy with cyclophosphamide 600 mg/sqm, methotrexate 40 mg/sqm and 5-fluorouracyl 600 mg/sqm days 1,8. Subsequent follow-up was negative until September 2005 when a local left axillary relapse was resected. Histological and biological features of the relapse did not change. Surgical resection was followed, from January to February 2006, by radiation therapy on the left chest wall (5000 cGy with fractioned dose of 200 cGy/day). In November 2010, a PET-CT scan was performed to test for progressive increase in serum biomarkers. It showed multiple secondary localizations: lymph-nodal metastases (left axillary, mediastinic, iliac and lombo-aortic), liver metastases (third segment), and bone lesions (left seventh rib and left femur acetabulum). Liver biopsy confirmed hormone receptors negativity and HER2 overexpression (score 3+). The patient was absolutely asymptomatic (ECOG 0). A screening echocardiogram (January 2011) found no pathological findings and a normal left ventricular ejection fraction (LVEF 64%). At that point, first line chemotherapy with weekly paclitaxel (80 mg/sqm) associated with weekly trastuzumab (loading dose of 4 mg/kg followed by maintenance dose of 2 mg/Kg) was initiated and paclitaxel was withdrawn at the second administration because of hypersensitivity reaction and replaced with docetaxel (100 mg/sqm every three weeks). A supportive therapy with bisphophonates (zoledronic acid 4 mg i.v. every 28 days) was also administered for bone metastases. In March 2011, after three months of treatment (fourteen administrations of weekly trastuzumab), the patient referred asthenia, tachycardia, increasing dyspnea for mild efforts and palpitations. Within few days clinical conditions rapidly worsened and the patient was admitted to the emergency room for cardiogenic shock (heart rate 150 beats per minute, blood pressure 70/50 mmHg, severe oliguria, pulmonary congestion, NYHA 4, AHA D). An angio-CT scan excluded a pulmonary thromboembolism and the patient was admitted to a cardiac intensive care unit where an echocardiogram revealed a severe global biventricular dilatation and dysfunction (LVEF about 15%). Despite a maximal supportive therapy with inotropic agents and diuretics, shock persisted. Therefore an intraortic balloon pump was implanted with a very slow but progressive hemodynamic improvement and a resumption of diuresis. In absence of previous clinical experiences or data from the literature describing of similar serious clinical presentation using trastuzumab alone (without current or previous history of anthracyclines exposure), a myocardium biopsy was performed finding inflammatory areas of uncertain etiology but not compatible with a myocarditis. After approximately two months of hospitalization the patient was progressively weaned by inotropic agents and infusional diuretic therapy, and a heart failure pharmacological treatment was orally introduced (bisoprolol 2,5 mg, enalapril 2,5 mg, ivabradine 15 mg, canreonate 50 mg, furosemide 100 mg). After four months and with a slow pharmacological up-titration, we observed a progressive clinical improvement and an increase and stabilization of biventricular function (LVEF 45% on September 2011). In May 2012, a PET-CT scan showed lymph-nodal, liver and skeletal disease progression, at which point a second line chemotherapy with vinorelbine (25 mg/sqm, days 1,8) was initiated. In July 2012, after two cycles of chemotherapy, a further tumor assessment documented visceral disease progression. Therefore, with awareness of the high risk due to recent severe cardiogenic shock and after discussion with the patient and her family, we decided to resume trastuzumab therapy along with cardiac therapy. Weekly trastuzumab (2 mg/kg) was resumed with a clinical and echocardiographic cardiac monitoring. Soon thereafter, radiological evaluations (PET-CT scan and total body CT scan) showed a partial response of visceral disease. Trastuzumab and vinorelbine therapy was continued until June 2013 when, considering the positive response and the appearance of grade 2 neuropathy, vinorelbine was interrupted and trastuzumab was continued every 21 days (6 mg/Kg) until April 2014 with no further signs or symptoms of heart failure. External beam radiotherapy on left ileo-pubic branch (March 2012, 30 Gy) and on the second cervical vertebra (January 2013, 2000 cGy for 5 fractions) were performed for palliative purpose. Zoledronic acid every 28 days was continued during the whole period. Serial echocardiograms performed during trastuzumab treatment did not reveal LVEF drop maintaining in the range of 50–55%.\nIn January 2014 the patient presented diplopia, left eye squint, postural instability and leg weakness. A CT scan and MRI (February 2014) revealed the presence of four cerebral and cerebellar lesions (right cerebellar tonsil, left frontal and parietal lobe, quadrigeminal plate). The patient underwent stereotactic gamma-knife radiosurgery on February 2014 followed by whole brain irradiation for suspected leptomeningeal involvement (3000 cGy for 12 fractions). In April 2014 trastuzumab was interrupted and a new line of chemotherapy with capecitabine 3000 mg/day (1–14 every 21 days) associated with tyrosine kinase inhibitor (TKI) lapatinib 250 mg 4 tb/day was started. Subsequent radiological assessment (August 2015) documented a complete remission of lymph-nodal and liver neoplastic disease and radiologic stability of bone metastases.\nIn November 2014 the patient was hospitalized for acute renal failure secondary to dehydration, fainting and recurrent vomiting. After discharge, she complained of severe asthenia, anorexia and weight loss. Consequently, chemotherapy with capecitabine was suspended and lapatinib was continued as monotherapy for about a year during which she never reported cough, dyspnea, chest pain and other symptoms suggestive of heart failure (NYHA II, AHA C). In November 2015, echocardiographic examination showed no relevant changes compared to the previous ones. We found an interesting pattern of LVEF trend along with trastuzumab treatment – discontinuation – and resumption .\nOver the following three months, the patient experienced a rapid deterioration of general clinical conditions, with progressive and definitive bedrest and altered conscience, suggesting a meningeal disease progression. In January 2016, the last ultrasound examination showed a progressive liver disease. The patient died on February 24, 2016 from neoplastic disease progression.", + "fulltext_subclaims": [ + "The patient was a 49 year-old woman.", + "In December 2000, she underwent left mastectomy.", + "The tumor was stage IIA invasive ductal breast carcinoma.", + "The tumor had low proliferative activity (Ki 67 < 5%).", + "The tumor was negative for hormone receptors.", + "The tumor had HER2 overexpressed (score 3+ at immunochemistry).", + "She had no cardiovascular comorbidities.", + "She had no family history of cardiovascular disease.", + "From February to July 2001, she received adjuvant chemotherapy with cyclophosphamide 600 mg/sqm, methotrexate 40 mg/sqm and 5-fluorouracyl 600 mg/sqm days 1,8.", + "Subsequent follow-up was negative until September 2005.", + "In September 2005, a local left axillary relapse was resected.", + "Histological and biological features of the relapse did not change.", + "Surgical resection was followed by radiation therapy on the left chest wall from January to February 2006.", + "The radiation therapy delivered 5000 cGy with fractioned dose of 200 cGy/day.", + "In November 2010, a PET-CT scan showed multiple secondary localizations.", + "The PET-CT scan showed lymph-nodal metastases (left axillary, mediastinic, iliac and lombo-aortic).", + "The PET-CT scan showed liver metastases (third segment).", + "The PET-CT scan showed bone lesions (left seventh rib and left femur acetabulum).", + "Liver biopsy confirmed hormone receptors negativity.", + "Liver biopsy confirmed HER2 overexpression (score 3+).", + "The patient was absolutely asymptomatic (ECOG 0).", + "A screening echocardiogram in January 2011 found no pathological findings.", + "The echocardiogram showed a normal left ventricular ejection fraction (LVEF 64%).", + "First line chemotherapy with weekly paclitaxel (80 mg/sqm) associated with weekly trastuzumab (loading dose of 4 mg/kg followed by maintenance dose of 2 mg/Kg) was initiated.", + "Paclitaxel was withdrawn at the second administration because of hypersensitivity reaction.", + "Paclitaxel was replaced with docetaxel (100 mg/sqm every three weeks).", + "A supportive therapy with bisphophonates (zoledronic acid 4 mg i.v. every 28 days) was administered for bone metastases.", + "In March 2011, after three months of treatment, the patient referred asthenia, tachycardia, increasing dyspnea for mild efforts and palpitations.", + "Within few days clinical conditions rapidly worsened.", + "The patient was admitted to the emergency room for cardiogenic shock.", + "An angio-CT scan excluded a pulmonary thromboembolism.", + "An echocardiogram revealed a severe global biventricular dilatation and dysfunction (LVEF about 15%).", + "An intraortic balloon pump was implanted.", + "A myocardium biopsy was performed.", + "The biopsy found inflammatory areas of uncertain etiology.", + "The biopsy findings were not compatible with a myocarditis.", + "After approximately two months of hospitalization, the patient was weaned by inotropic agents.", + "A heart failure pharmacological treatment was orally introduced.", + "In May 2012, a PET-CT scan showed lymph-nodal, liver and skeletal disease progression.", + "A second line chemotherapy with vinorelbine (25 mg/sqm, days 1,8) was initiated.", + "In July 2012, after two cycles of chemotherapy, a further tumor assessment documented visceral disease progression.", + "Trastuzumab therapy was resumed.", + "Weekly trastuzumab (2 mg/kg) was resumed with a clinical and echocardiographic cardiac monitoring.", + "Radiological evaluations showed a partial response of visceral disease.", + "Trastuzumab and vinorelbine therapy was continued until June 2013.", + "Vinorelbine was interrupted due to grade 2 neuropathy.", + "Trastuzumab was continued every 21 days (6 mg/Kg) until April 2014.", + "Serial echocardiograms performed during trastuzumab treatment did not reveal LVEF drop.", + "In January 2014, the patient presented diplopia, left eye squint, postural instability and leg weakness.", + "A CT scan and MRI revealed four cerebral and cerebellar lesions.", + "The patient underwent stereotactic gamma-knife radiosurgery.", + "Whole brain irradiation was performed for suspected leptomeningeal involvement.", + "Trastuzumab was interrupted in April 2014.", + "A new line of chemotherapy with capecitabine 3000 mg/day and lapatinib 250 mg 4 tb/day was started.", + "Subsequent radiological assessment documented a complete remission of lymph-nodal and liver neoplastic disease.", + "In November 2014, the patient was hospitalized for acute renal failure.", + "Chemotherapy with capecitabine was suspended.", + "Lapatinib was continued as monotherapy.", + "In November 2015, echocardiographic examination showed no relevant changes.", + "The patient experienced a rapid deterioration of general clinical conditions.", + "The patient died on February 24, 2016 from neoplastic disease progression." + ], + "summary": "We report the case of a 49 year-old woman affected by metastatic breast cancer who developed trastuzumab-related cardiogenic shock due to pump failure (with LVEF of about 15%) after three months of treatment. After a long hospitalization in the cardiac intensive care unit and a proper treatment, LVEF increased to 50% and, due to a severe progression of disease, trastuzumab was resumed and continued for more than one year.", + "summary_subclaims": [ + "The patient was a 49 year-old woman.", + "The patient had metastatic breast cancer.", + "The patient developed trastuzumab-related cardiogenic shock due to pump failure.", + "The patient's LVEF was about 15%.", + "The cardiogenic shock occurred after three months of trastuzumab treatment.", + "The patient was hospitalized in the cardiac intensive care unit.", + "The patient's LVEF increased to 50% after treatment.", + "Trastuzumab was resumed due to a severe progression of disease.", + "Trastuzumab was continued for more than one year." + ] + }, + { + "id": "multiclinsum_test_2157_en.txt", + "fulltext": "A male, 72 years old. No physical discomfort, a physical examination, and gastroscopy are required.\nDue to a regular physical examination, the gastroscopy found that the lower end of the stomach was marked with shallow depression near the antrum, with surface flushing and a tuberosity bulge in the centre . Then a biopsy. The indigo carmine staining is shallow depression, and the surrounding boundary is clear . Consider the patient’s atrophic gastritis with gastric antrum erosion and gastric antrum body junction lesions.\nIn the past medical history of patients, he had a history of hypertension and diabetes. Now blood pressure and blood glucose are perennial oral drug control. They denied others the history of chronic diseases, and the history of infectious diseases such as hepatitis, tuberculosis, and schistosomiasis.\nThe patient denied any family history of malignant tumours. There is no history of Helicobacter pylori infection.\nPhysical examination revealed no fever, heart rate 77 bpm, blood pressure 141/85 mmHg, and other examinations all have discomfort.\nAfter admission, the patient improved the examination of tumour indicators, and the results were negative .\nNo obvious abnormality in the upper abdominal enhanced computed tomography (CT) revealed no concurrent lymph node and distant metastasis .\nPathology revealed high-grade intraepithelial neoplasia in the mucosa. The patient was subsequently examined after admission. Narrow-band imaging (NBI) after admission revealed a station membrane hyperemia lesion on the posterior wall of the gastric antrum. The staining showed that the lesion was a shallow depression with an unclear boundary. At the outer layer of the tumor, the micro glandular tube structure was disorganized and variable in size. The microvessels were slightly tortuous and expanded, forming a bright boundary with the periphery, with an endoscopic lesion ranging from 5 mm × 6 mm .\nEndoscopic ultrasonography (EUS) was used to determine the source of the stomach wall. The local area is slightly thickened, the other levels of the stomach wall are continuous and complete, and there are no obvious abnormal echoes. The diagnosis was that the lesion was in the gastric mucosa .\nImmunohistochemical examination revealed Ki-67 positivity in tissue , partial MUC2 positivity , partial MUC5AC negativity and partial MUC6 positivity . Hematoxylin and eosin were detected , after which poorly differentiated adenocarcinoma cells were detected.\nHematoxylin and eosin staining revealed that the lesions were at the level of the neck of the gland and continued with the surface epithelium. Determining the tumor boundaries is difficult. There were “crawling type” glands everywhere in the tumour’s vicinity. Moreover, it spreads laterally in the lamina propria, but not in the stomach glands.", + "fulltext_subclaims": [ + "The patient is a 72-year-old male.", + "The gastroscopy found that the lower end of the stomach was marked with shallow depression near the antrum.", + "The lesion had surface flushing and a tuberosity bulge in the centre.", + "A biopsy was performed.", + "The indigo carmine staining showed a shallow depression.", + "The surrounding boundary of the lesion was clear.", + "The patient had a history of hypertension.", + "The patient had a history of diabetes.", + "The patient denied a history of Helicobacter pylori infection.", + "The patient denied a family history of malignant tumours.", + "The patient denied a history of hepatitis, tuberculosis, and schistosomiasis.", + "The patient had no fever on physical examination.", + "The patient's heart rate was 77 bpm.", + "The patient's blood pressure was 141/85 mmHg.", + "The upper abdominal enhanced CT showed no concurrent lymph node and distant metastasis.", + "Pathology revealed high-grade intraepithelial neoplasia in the mucosa.", + "Narrow-band imaging revealed a station membrane hyperemia lesion on the posterior wall of the gastric antrum.", + "The staining showed that the lesion was a shallow depression with an unclear boundary.", + "The endoscopic lesion measured 5 mm × 6 mm.", + "Endoscopic ultrasonography showed that the local area of the stomach wall was slightly thickened.", + "The other levels of the stomach wall were continuous and complete.", + "The diagnosis was that the lesion was in the gastric mucosa.", + "Immunohistochemical examination revealed Ki-67 positivity in tissue.", + "Hematoxylin and eosin staining revealed poorly differentiated adenocarcinoma cells.", + "The lesions were at the level of the neck of the gland and continued with the surface epithelium.", + "Determining the tumor boundaries was difficult.", + "There were 'crawling type' glands everywhere in the tumour’s vicinity.", + "The tumor spreads laterally in the lamina propria.", + "The tumor does not spread in the stomach glands." + ], + "summary": "Here, we report the case of a patient who underwent ordinary endoscopy, narrow-band imaging, and endoscopic ultrasonography intending to determine the extent of tumor invasion and upper abdominal enhanced computed tomography and whether there was tumor metastasis. Then, endoscopic submucosal dissection was performed. After pathological and immunohistochemical examination, the pathological diagnosis was crawling-type gastric adenocarcinoma. This is a very rare and special pathological type of tumor. This case highlights the importance of using advanced endoscopic techniques and pathological examination in diagnosing and managing gastric crawling-type adenocarcinoma. Moreover, the findings underscore the need for continued research and clinical experience in this rare subtype of GC to improve patient outcomes.", + "summary_subclaims": [ + "The patient underwent ordinary endoscopy.", + "The patient underwent narrow-band imaging.", + "The patient underwent endoscopic ultrasonography.", + "The patient underwent upper abdominal enhanced computed tomography.", + "The patient underwent endoscopic submucosal dissection.", + "After pathological and immunohistochemical examination, the pathological diagnosis was crawling-type gastric adenocarcinoma.", + "Crawling-type gastric adenocarcinoma is a very rare and special pathological type of tumor.", + "This case highlights the importance of using advanced endoscopic techniques and pathological examination in diagnosing and managing gastric crawling-type adenocarcinoma.", + "The findings underscore the need for continued research and clinical experience in this rare subtype of GC to improve patient outcomes." + ] + }, + { + "id": "multiclinsum_test_2208_en.txt", + "fulltext": "In April 2015, a 23-year-old male was referred to our Faculty (Oral and Maxillofacial disease department of Mashhad university of Medical sciences). His chief complaint was an ulcer of the uvulae from three months ago, oropharyngeal dysphagia, pharyngitis, and mild fever with unintentional 20-pound weight loss over the course of 4 months. Also he was on a mechanical soft diet. Over the past four years, he had severe episodes of Pharyngitis without response to the usual administered drugs, as well as a history of severe dental infection involving the brain. He did not have any systemic disorders and no history of smoking, abusing drugs or drinking alcohol. He was a construction worker and often dealt with rock wool. Upon physical examination, two painful destructive ulcers were observed. One of them was about 2cm × 1 cm, extending from the soft palate to hard palate, exposing the underlying bone and another one was destructing the uvulae . The ulcers were covered with a thick fibrinoleukocyter membrane with erythematous borders. He had no history of such lesions. His oral hygiene was in good condition. Cervical lymph nodes were not appreciable. Disseminated hypopigmented maculopapular rash throughout the skin, from nine years ago, was also observed. Examination of vital signs revealed a blood pressure of 110/70 mm Hg, a heart rate of 80 beats per minute, and a body temperature of 100°F. The rest of his physical examination did not raise any concerns.\nThe patient had been initially admitted to the Ear, Nose and Throat department two months ago. Due to suspicion of an infective condition (Trench mouth), some antibiotics such as Ceftriaxone, Metronidazole and Clindamycin were administered for about one month but without significant improvement.\nBecause of the negative response to the drugs mentioned above the suspicion of an immunosuppressive condition was raised. Therefore, the patient was admitted to the allergy and immunology department. After consultation with an infectious disease specialist, the administered antibiotics were altered to Ceftazidime, Vancomycin, and Metronidazole. However, despite taking these remedies for about three weeks, no improvement was observed. Along with these treatments, some laboratory tests and paraclinical modalities had been requested below:\nThe blood test only showed Neutrophilia (about 80% of the white blood cell count) and Lymphocytopenia. Erythrocyte sedimentation rate was high and C-reactive protein was positive. Serum chemistry parameters were in normal range. All of the virology, microbiology and parasitology tests; such as Anti-HIV, Tuberculin skin testing, etc.; were negative. He had a high Lactate dehydrogenase level of about 595 IU/L. Given the patient's fevers, history of recurrent upper respiratory tract infection with depigmented skin rashes, Infectious mononucleosis was a concern when white blood cell morphology was studied and viral type Lympho-Mono were seen. Also viral capsid antigen (VCA)-IgM and VCA-IgG were dramatically high in the patient’s serum. The results of nitro blue Tetrazolium test NBT and Dihydrorhodamine Flow cytometric Assay (DHR) and other immunological laboratory findings were in normal ranges, except for high IgE (2375 µ/dl) and a slightly low IgM (25 mg/dl). Consequently Immunodeficiency and autoimmune disease were not confirmed. Paraclinical modalities such as Abdominal, Inguinal and Neck ultrasonography, Chest X-ray, Posterior-Anterior Skull X-ray were requested and no abnormalities were observed, except for multiple reactive lymph nodes up to 12 millimeters in size at the anterior cervical lymph node chain, which were detected by ultrasonography. Computed tomography (CT) scan of the head and neck with contrast medium revealed nothing of note. In addition, biopsy from palatal ulcers with fungal culture revealed a non-specific ulcer with extensive necrosis and bacterial colonies, fibrin deposition and vasculitis. Dysplasia, malignancy any fungal elements were not evident.\nA biopsy of the palatal ulcers was repeated and the histopathological examination of the specimen showed very dense lymphocyte infiltration. In the background of the tissue, lymphoid cell with atypia, irregular and prominent nuclei were seen. The benign inflammatory cell infiltration with geographic necrosis in the background was evident . After consultation, the patient was referred to our Faculty and two clinical provisional diagnoses were made: The first one was a Lymphoproliferative disease such as Non-Hodgkin lymphoma and the second one was necrotizing stomatitis accompagnied by immunocompromised conditions and viral infections like EBV, cytomegaloviruses (CMV) and Herpes simplex viruses (HSV). Hence immunohistochemical analysis of paraffin blocks was requested. CD3 was expressed in some background lymphoid cells, CD56 was positive in some lymphoid cells, CD20 was positive in some background lymphocytes, and the Ki-67 marker was positive in 60% of background of Lymphoid cells. Terminal deoxynucleotidyl transferase (TdT) was negative and finally the diagnosis of ENKL was confirmed . Clinical staging of the lymphoma according to the Ann Arbor classification was determined as stage IE (4). The patient was referred to the oncologist and a CHOP regimen of chemotherapy was administered every three weeks. After the third cycle of CHOP therapy, the patient unfortunately died due to sepsis and infection (about 3 months after treatment).", + "fulltext_subclaims": [ + "The patient was a 23-year-old male.", + "The patient was referred to the Oral and Maxillofacial disease department of Mashhad university of Medical sciences.", + "The patient had an ulcer of the uvulae from three months ago.", + "The patient had oropharyngeal dysphagia.", + "The patient had pharyngitis.", + "The patient had mild fever.", + "The patient had unintentional 20-pound weight loss over the course of 4 months.", + "The patient was on a mechanical soft diet.", + "The patient had severe episodes of Pharyngitis without response to the usual administered drugs.", + "The patient had a history of severe dental infection involving the brain.", + "The patient did not have any systemic disorders.", + "The patient had no history of smoking, abusing drugs, or drinking alcohol.", + "The patient was a construction worker.", + "The patient often dealt with rock wool.", + "Physical examination showed two painful destructive ulcers.", + "One ulcer was about 2cm × 1 cm, extending from the soft palate to hard palate.", + "The ulcers were covered with a thick fibrinoleukocyter membrane with erythematous borders.", + "The patient had no history of such lesions.", + "The patient had disseminated hypopigmented maculopapular rash throughout the skin from nine years ago.", + "The patient's blood pressure was 110/70 mm Hg.", + "The patient's heart rate was 80 beats per minute.", + "The patient's body temperature was 100°F.", + "The patient had been initially admitted to the Ear, Nose and Throat department two months ago.", + "Antibiotics such as Ceftriaxone, Metronidazole, and Clindamycin were administered for about one month.", + "The administered antibiotics did not result in significant improvement.", + "The suspicion of an immunosuppressive condition was raised.", + "The patient was admitted to the allergy and immunology department.", + "The administered antibiotics were altered to Ceftazidime, Vancomycin, and Metronidazole.", + "The patient was taking these antibiotics for about three weeks.", + "No improvement was observed.", + "The blood test showed Neutrophilia (about 80% of the white blood cell count).", + "The blood test showed Lymphocytopenia.", + "Erythrocyte sedimentation rate was high.", + "C-reactive protein was positive.", + "Serum chemistry parameters were in normal range.", + "All virology, microbiology, and parasitology tests were negative.", + "The patient had a high Lactate dehydrogenase level of about 595 IU/L.", + "Infectious mononucleosis was a concern.", + "Viral type Lympho-Mono was seen in the white blood cell morphology.", + "Viral capsid antigen (VCA)-IgM and VCA-IgG were dramatically high in the patient’s serum.", + "The results of nitro blue Tetrazolium test NBT and Dihydrorhodamine Flow cytometric Assay (DHR) were in normal ranges.", + "The patient had high IgE (2375 µ/dl).", + "The patient had a slightly low IgM (25 mg/dl).", + "Immunodeficiency and autoimmune disease were not confirmed.", + "Abdominal, Inguinal, and Neck ultrasonography were requested.", + "Chest X-ray was requested.", + "Posterior-Anterior Skull X-ray was requested.", + "Multiple reactive lymph nodes up to 12 millimeters in size were detected by ultrasonography.", + "Computed tomography (CT) scan of the head and neck with contrast medium revealed nothing of note.", + "Biopsy from palatal ulcers with fungal culture revealed a non-specific ulcer with extensive necrosis and bacterial colonies.", + "Dysplasia was not evident.", + "Malignancy was not evident.", + "Fungal elements were not evident.", + "The histopathological examination showed very dense lymphocyte infiltration.", + "Lymphoid cells with atypia, irregular and prominent nuclei were seen.", + "Benign inflammatory cell infiltration with geographic necrosis in the background was evident.", + "The clinical provisional diagnoses were Lymphoproliferative disease such as Non-Hodgkin lymphoma and necrotizing stomatitis accompanied by immunocompromised conditions and viral infections.", + "Immunohistochemical analysis of paraffin blocks was requested.", + "CD3 was expressed in some background lymphoid cells.", + "CD56 was positive in some lymphoid cells.", + "CD20 was positive in some background lymphocytes.", + "The Ki-67 marker was positive in 60% of background lymphoid cells.", + "Terminal deoxynucleotidyl transferase (TdT) was negative.", + "The diagnosis of ENKL was confirmed.", + "Clinical staging of the lymphoma according to the Ann Arbor classification was stage IE.", + "The patient was referred to the oncologist.", + "A CHOP regimen of chemotherapy was administered every three weeks.", + "After the third cycle of CHOP therapy, the patient died due to sepsis and infection.", + "The patient died about 3 months after treatment." + ], + "summary": "The present study examines a case of NKTCL in a 23-year-old man with a destructive ulcer of the palate and uvulae. Based on immunohistochemical results, after three months of delay, the definitive diagnosis was revealed to be Extranodal NK/T cell lymphoma. Following the third cycle of chemotherapy, the patient died due to sepsis and infection.", + "summary_subclaims": [ + "The present study examines a case of NKTCL in a 23-year-old man.", + "The patient had a destructive ulcer of the palate and uvulae.", + "The definitive diagnosis was Extranodal NK/T cell lymphoma.", + "The definitive diagnosis was revealed after three months of delay.", + "The definitive diagnosis was based on immunohistochemical results.", + "Following the third cycle of chemotherapy, the patient died.", + "The patient died due to sepsis and infection." + ] + }, + { + "id": "multiclinsum_test_2927_en.txt", + "fulltext": "A 61-year-old man with mild obesity, treated for T2DM with empagliflozin 10 mg/d, metformin 2000 mg/d and recently 12 units/day of long-acting insulin, underwent elective hip replacement surgery. Pre-operative assessment was unremarkable, with a low estimated risk of anesthesia (ASA 2). No oral antidiabetic agents were administered the evening before surgery. The surgery performed on day 1 (D1) was uneventful, as was the stay in the HDU. The administration of empagliflozin, metformin and insulin in chronic doses was resumed on D2. The patient was transferred to a ward on D3. On D4, the patient felt unwell and vomited once, but his condition improved after administration of metoclopramide. The attending physician revealed no remarkable findings. Blood gas analysis was not performed. On D5, the patient still felt unwell but without any specific complaints such as chest pain or dyspnea. Glycemia was below 10 mmol/l. In the evening, the patient vomited again. One hour later he suddenly collapsed due to cardiac arrest by ventricular fibrillation. CPR was started immediately, with ROSC after 35 min. Post-arrest ECG and echocardiography suggested acute myocardial infarction. Immediate coronary angiography revealed several significant chronic coronary artery stenoses but no acute culprit lesion, consistent with only minimal troponin T elevations over the following days. The left ventricle ejection fraction was 30–35% and there were no echocardiography findings suggestive of pulmonary embolism. On admission to the ICU, the patient was anuric and required norepinephrine. He died on D8 due to severe post-hypoxic brain injury.\nOn admission to the ICU one hour after CPR, a severe mixed metabolic acidosis was present with pH of 6.85 and base excess of -29 mmol/l . Lactate was only moderately elevated (5.8 mmol/l). An elevated beta-hydroxybutyrate concentration of 3.2 mmol/l. Corresponded to a mild ketoacidosis . Together with lactate and acetoacetate, whose concentration is about three times lower than that of beta-hydroxybutyrate, the total organic acid concentration was about 10 mmol/l. The anion gap was 18.1 mmol/l, i.e. 9.6 mmol/l higher than expected . Thus, the increase in the anion gap can be explained entirely by organic acids, with no other component. Subtracting this increase in anion gap still leaves a base excess of almost − 20 mmol/l, which must be explained by a non-anion gap hyperchloremic acidosis (admission Cl− was 117 mmol/l, see Table ). Overall, we found a mixed metabolic acidosis - lactic acidosis, ketoacidosis and hyperchloremic acidosis. We consider the lactic acidosis to be a consequence of cardiac arrest, but the other components of the acidosis, with base excess of -23 mmol/L after subtraction of the lactate, must have been present before CPR. We found no etiological explanation for the acidosis other than the SGLT2i-associated ketoacidosis. We hypothesize that SGLT2i gradually induced severe acidosis within 5 days of surgery, which triggered a malignant arrhythmia in the context of previously undiagnosed coronary artery disease. Here, we briefly review the pathogenesis of SGLT2i-associated acidosis and discuss some specific points of the presented case.", + "fulltext_subclaims": [ + "The patient was a 61-year-old man with mild obesity.", + "He was treated for T2DM with empagliflozin 10 mg/d, metformin 2000 mg/d, and recently 12 units/day of long-acting insulin.", + "He underwent elective hip replacement surgery.", + "Pre-operative assessment was unremarkable with a low estimated risk of anesthesia (ASA 2).", + "No oral antidiabetic agents were administered the evening before surgery.", + "The surgery on day 1 was uneventful.", + "The stay in the HDU was uneventful.", + "Empagliflozin, metformin, and insulin in chronic doses were resumed on day 2.", + "The patient was transferred to a ward on day 3.", + "On day 4, the patient felt unwell and vomited once.", + "His condition improved after administration of metoclopramide.", + "The attending physician revealed no remarkable findings.", + "Blood gas analysis was not performed.", + "On day 5, the patient still felt unwell but without specific complaints such as chest pain or dyspnea.", + "Glycemia was below 10 mmol/l.", + "In the evening, the patient vomited again.", + "One hour later he suddenly collapsed due to cardiac arrest by ventricular fibrillation.", + "CPR was started immediately.", + "ROSC was achieved after 35 minutes.", + "Post-arrest ECG and echocardiography suggested acute myocardial infarction.", + "Immediate coronary angiography revealed several significant chronic coronary artery stenoses.", + "There was no acute culprit lesion.", + "Troponin T elevations were minimal over the following days.", + "The left ventricle ejection fraction was 30–35%.", + "There were no echocardiography findings suggestive of pulmonary embolism.", + "On admission to the ICU, the patient was anuric and required norepinephrine.", + "He died on day 8 due to severe post-hypoxic brain injury.", + "On admission to the ICU, a severe mixed metabolic acidosis was present with pH of 6.85 and base excess of -29 mmol/l.", + "Lactate was moderately elevated at 5.8 mmol/l.", + "Beta-hydroxybutyrate concentration was 3.2 mmol/l.", + "The anion gap was 18.1 mmol/l.", + "The increase in the anion gap can be explained entirely by organic acids.", + "The increase in the anion gap was 9.6 mmol/l higher than expected.", + "Subtracting the increase in anion gap still leaves a base excess of almost −20 mmol/l.", + "The base excess after subtraction of lactate must be explained by a non-anion gap hyperchloremic acidosis.", + "We found a mixed metabolic acidosis - lactic acidosis, ketoacidosis, and hyperchloremic acidosis.", + "We consider the lactic acidosis to be a consequence of cardiac arrest.", + "The other components of the acidosis must have been present before CPR.", + "We found no etiological explanation for the acidosis other than SGLT2i-associated ketoacidosis.", + "We hypothesize that SGLT2i gradually induced severe acidosis within 5 days of surgery.", + "We hypothesize that the acidosis triggered a malignant arrhythmia in the context of previously undiagnosed coronary artery disease." + ], + "summary": "A patient with type 2 diabetes mellitus treated with empagliflozin underwent an elective hip replacement surgery. Since day 4 after surgery, he felt generally unwell, leading to cardiac arrest on the day 5. Empagliflozin-associated euglycemic diabetic ketoacidosis with severe hyperchloremic acidosis was identified as the cause of the cardiac arrest.", + "summary_subclaims": [ + "The patient had type 2 diabetes mellitus.", + "The patient was treated with empagliflozin.", + "The patient underwent an elective hip replacement surgery.", + "On day 4 after surgery, the patient felt generally unwell.", + "Cardiac arrest occurred on day 5 after surgery.", + "Empagliflozin-associated euglycemic diabetic ketoacidosis was identified as the cause of the cardiac arrest.", + "Severe hyperchloremic acidosis was identified as the cause of the cardiac arrest." + ] + }, + { + "id": "multiclinsum_test_1185_en.txt", + "fulltext": "A 10-year-old Kurdish boy presented with bone pain and fever associated with night sweats, shortness of breath, weight loss (5kg/month), purple purpuric spots over the skin and bleeding from the nose. The patient’s history dated back to 1 month before admission. On examination, we observed pallor, cachexia, dyspnea, fever, tachycardia, tachypnea, multiple petechiae and ecchymoses all over the skin, dilated tortuous veins over the chest, pulse rate 120bpm, respiratory rate 23cycles/minute, temperature 39°C and blood pressure 90/45mmHg. Moreover, we found multiple small cervical lymphadenopathies and mild splenomegaly 3cm below the left costal margin. The boy’s liver was tender 7cm below the right costal margin, and he had gross abdominal distention. The initial blood counts were hemoglobin 64g/L, white blood cell count 34 × 109/L, platelets 25 × 109/L and blasts 38% (Figure\nA). The blasts were homogeneous with a high nuclear to cytoplasmic ratio, inconspicuous nucleoli and open chromatin, and some of the blasts were vacuolated. Platelets were markedly reduced (Figure\nB). There was mediastinal widening visualized on a chest X-ray (Figure\n). MRI showed lumbosacral vertebrae with diffuse infiltration of the axial bone marrow of the lower dorsal and lumbar vertebrae, suggestive of bony metastases predominantly osteolytic in nature (Figure\nA–\nC). Bone marrow aspiration (BMA) showed no fragments but few areas of necrosis. Bone marrow biopsy showed marked BMN (Figure\nA and\nB). The first immunophenotyping was not conclusive, but the second was positive for CD3 and terminal deoxynucleotidyl transferase and negative for CD20, CD79a and CD10.\nAfter admission, the patient’s condition deteriorated and features of frank superior vena cava syndrome developed. The patient was treated with chemotherapy according to the ALL protocol, and complete remission was achieved on day 28. At the 24th week of chemotherapy, his condition relapsed on treatment. He returned to our hospital with fever, chest infection and 60% blasts observed on peripheral blood film, and the complete blood count revealed severe pancytopenia. The BMA was a dry tap, but the biopsy showed hypercellular marrow with extensive infiltration by mononuclear cells and disappearance of necrosis (Figure\nC and\nD). Treatment was reinitiated according to the ALL protocol (bone marrow relapsed protocol), after which he developed severe mucositis, uncontrolled septicemia and electrolyte imbalance. Eventually, that led to death.\nThe BMA at the time of diagnosis was diluted, and the slides appeared to show artefact with a few necrotic cells. The biopsy was a 1.6cm piece of tissue that consisted of a fragment of trabecular bone showing marked BMN, as shown in the image in Figure\nA (before treatment). The result of immunohistochemistry was not interpretable for the first specimen, but for the second the diagnosis was definitive as precursor T-cell ALL.\nDuring admission, we gave the patient intravenous fluid 3000ml/m2/day, allopurinol tablets 100mg/m2/dose and antibiotics. The patient’s condition subsequently deteriorated, and he developed progressive dyspnea, chest tightness, abdominal distention and fever. The patient was near to developing frank features of superior vena cava syndrome, but later he developed bilateral lower-limb weakness. The straight leg raising test was observed to be positive bilaterally. MRI of the dorsolumbosacral spine showed diffuse focal infiltration of the axial bone marrow of the lower dorsal and lumbar vertebrae causing altered hypointense T1-weighted signal intensity (Figure\nA and\nB). The image was suggestive of bony metastasis that was predominantly osteolytic in nature (Figure\nA and\nB). Incidental hepatosplenomegaly and bilateral renal enlargement were also observed (Figure\nC), but there was no pressure on the spinal cord.\nWe started dexamethasone intravenous infusion at 6mg/m2. Seven days after the patient’s admission, we started induction therapy with vincristine 1.5mg/m2 intravenous bolus on days 7, 14, 21 and 28. Dexamethasone 6mg/m2 was administered daily, and daunorubicin 25mg/m2 was given on the days 1 and 7.\nUpon starting induction, the patient developed attacks of tonic-clonic contractions. We found computed tomography of the brain without contrast to be negative. Electrolyte measurements showed severe hypocalcemia, and we induced correction, which stabilized the convulsions. On day 28, BMA indicated a few fragments and megakaryocytes were seen. Erythroid and myeloid series were present with all stages of maturation. The data also indicated predominant neutrophils and histiocytes, but the cellular elements could not confirm an excess of blast cells. The bone marrow biopsy report showed 95% cellularity, which was composed predominantly of early-stage granulocytes and normal maturation stages of hematopoietic cells. The blasts constituted about 2% of total marrow nucleated cells. The myeloid to erythroid cell ratio was 8:1.\nAfter a 4-week induction period, complete remission was observed and we continued giving the early consolidation chemotherapy. Unfortunately, at the 24th week of treatment, the patient returned with fever, chest infection, neutropenia and thrombocytopenia, and we found the presence of a few blasts in the peripheral blood film. The patient was not responding to supportive treatment that included antibiotics and antipyretics. The follow-up analysis of BMA showed excessive bone marrow infiltration by mononuclear cells with multiple inconspicuous nucleoli. Both erythroid and megakaryocytic precursors were suppressed in BMA, whereas in relapsed biopsy no necrosis was observed (Figure\nC and\nD).\nOn the reinduction therapy date, we followed a bone marrow relapsed protocol. On the 14th day of treatment reinduction, the patient developed severe anemia, thrombocytopenia and neutropenia. In addition, he developed grade IV mucositis with hypokalemia. The patient could not tolerate the complications, and he developed septicemia followed by sepsis. The patient’s death was an inevitable outcome. The overall survival period was 26 weeks after first diagnosis.", + "fulltext_subclaims": [ + "The patient was a 10-year-old Kurdish boy.", + "The patient presented with bone pain.", + "The patient had fever associated with night sweats.", + "The patient had shortness of breath.", + "The patient had weight loss of 5kg/month.", + "The patient had purple purpuric spots over the skin.", + "The patient had bleeding from the nose.", + "The patient’s history dated back to 1 month before admission.", + "On examination, we observed pallor.", + "On examination, we observed cachexia.", + "On examination, we observed dyspnea.", + "On examination, we observed fever.", + "On examination, we observed tachycardia.", + "On examination, we observed tachypnea.", + "On examination, we observed multiple petechiae and ecchymoses all over the skin.", + "On examination, we observed dilated tortuous veins over the chest.", + "The pulse rate was 120bpm.", + "The respiratory rate was 23cycles/minute.", + "The temperature was 39°C.", + "The blood pressure was 90/45mmHg.", + "We found multiple small cervical lymphadenopathies.", + "We found mild splenomegaly 3cm below the left costal margin.", + "The liver was tender 7cm below the right costal margin.", + "The patient had gross abdominal distention.", + "The initial blood counts were hemoglobin 64g/L.", + "The initial blood counts were white blood cell count 34 × 109/L.", + "The initial blood counts were platelets 25 × 109/L.", + "The initial blood counts showed blasts 38%.", + "The blasts were homogeneous with a high nuclear to cytoplasmic ratio.", + "The blasts had inconspicuous nucleoli.", + "The blasts had open chromatin.", + "Some of the blasts were vacuolated.", + "Platelets were markedly reduced.", + "There was mediastinal widening visualized on a chest X-ray.", + "MRI showed lumbosacral vertebrae with diffuse infiltration of the axial bone marrow of the lower dorsal and lumbar vertebrae.", + "The MRI findings were suggestive of bony metastases predominantly osteolytic in nature.", + "Bone marrow aspiration showed no fragments.", + "Bone marrow aspiration showed few areas of necrosis.", + "Bone marrow biopsy showed marked BMN.", + "The first immunophenotyping was not conclusive.", + "The second immunophenotyping was positive for CD3.", + "The second immunophenotyping was positive for terminal deoxynucleotidyl transferase.", + "The second immunophenotyping was negative for CD20.", + "The second immunophenotyping was negative for CD79a.", + "The second immunophenotyping was negative for CD10.", + "After admission, the patient’s condition deteriorated.", + "The patient developed frank superior vena cava syndrome.", + "The patient was treated with chemotherapy according to the ALL protocol.", + "Complete remission was achieved on day 28.", + "At the 24th week of chemotherapy, the patient’s condition relapsed on treatment.", + "The patient returned to the hospital with fever.", + "The patient returned to the hospital with chest infection.", + "The patient returned to the hospital with 60% blasts observed on peripheral blood film.", + "The complete blood count revealed severe pancytopenia.", + "Bone marrow aspiration was a dry tap.", + "The bone marrow biopsy showed hypercellular marrow.", + "The bone marrow biopsy showed extensive infiltration by mononuclear cells.", + "The bone marrow biopsy showed disappearance of necrosis.", + "Treatment was reinitiated according to the ALL protocol.", + "The patient developed severe mucositis.", + "The patient developed uncontrolled septicemia.", + "The patient developed electrolyte imbalance.", + "The patient eventually died.", + "The bone marrow aspiration at the time of diagnosis was diluted.", + "The slides showed artefact with a few necrotic cells.", + "The biopsy was a 1.6cm piece of tissue.", + "The biopsy consisted of a fragment of trabecular bone.", + "The biopsy showed marked BMN.", + "The result of immunohistochemistry was not interpretable for the first specimen.", + "The result of immunohistochemistry for the second specimen was definitive as precursor T-cell ALL.", + "During admission, the patient received intravenous fluid 3000ml/m2/day.", + "During admission, the patient received allopurinol tablets 100mg/m2/dose.", + "During admission, the patient received antibiotics.", + "The patient’s condition deteriorated.", + "The patient developed progressive dyspnea.", + "The patient developed chest tightness.", + "The patient developed abdominal distention.", + "The patient developed fever.", + "The patient was near to developing frank features of superior vena cava syndrome.", + "The patient developed bilateral lower-limb weakness.", + "The straight leg raising test was positive bilaterally.", + "MRI of the dorsolumbosacral spine showed diffuse focal infiltration of the axial bone marrow of the lower dorsal and lumbar vertebrae.", + "The MRI showed altered hypointense T1-weighted signal intensity.", + "The image was suggestive of bony metastasis that was predominantly osteolytic in nature.", + "Incidental hepatosplenomegaly was observed.", + "Incidental bilateral renal enlargement was observed.", + "There was no pressure on the spinal cord.", + "Dexamethasone intravenous infusion at 6mg/m2 was started.", + "Seven days after admission, induction therapy with vincristine 1.5mg/m2 intravenous bolus was started on days 7, 14, 21 and 28.", + "Dexamethasone 6mg/m2 was administered daily.", + "Daunorubicin 25mg/m2 was given on days 1 and 7.", + "Upon starting induction, the patient developed attacks of tonic-clonic contractions.", + "Computed tomography of the brain without contrast was negative.", + "Electrolyte measurements showed severe hypocalcemia.", + "Correction of hypocalcemia stabilized the convulsions.", + "On day 28, bone marrow aspiration indicated a few fragments.", + "On day 28, megakaryocytes were seen.", + "On day 28, erythroid and myeloid series were present with all stages of maturation.", + "On day 28, the data indicated predominant neutrophils and histiocytes.", + "On day 28, the cellular elements could not confirm an excess of blast cells.", + "The bone marrow biopsy report showed 95% cellularity.", + "The bone marrow biopsy showed predominant early-stage granulocytes.", + "The bone marrow biopsy showed normal maturation stages of hematopoietic cells.", + "The blasts constituted about 2% of total marrow nucleated cells.", + "The myeloid to erythroid cell ratio was 8:1.", + "After a 4-week induction period, complete remission was observed.", + "Early consolidation chemotherapy was continued.", + "At the 24th week of treatment, the patient returned with fever.", + "At the 24th week of treatment, the patient returned with chest infection.", + "At the 24th week of treatment, the patient returned with neutropenia.", + "At the 24th week of treatment, the patient returned with thrombocytopenia.", + "We found the presence of a few blasts in the peripheral blood film.", + "The patient was not responding to supportive treatment that included antibiotics and antipyretics.", + "Follow-up analysis of bone marrow aspiration showed excessive bone marrow infiltration by mononuclear cells.", + "Follow-up analysis of bone marrow aspiration showed multiple inconspicuous nucleoli.", + "Both erythroid and megakaryocytic precursors were suppressed in bone marrow aspiration.", + "In the relapsed biopsy, no necrosis was observed.", + "On the reinduction therapy date, we followed a bone marrow relapsed protocol.", + "On the 14th day of treatment reinduction, the patient developed severe anemia.", + "On the 14th day of treatment reinduction, the patient developed thrombocytopenia.", + "On the 14th day of treatment reinduction, the patient developed neutropenia.", + "The patient developed grade IV mucositis.", + "The patient developed hypokalemia.", + "The patient could not tolerate the complications.", + "The patient developed septicemia.", + "The patient developed sepsis.", + "The patient’s death was an inevitable outcome.", + "The overall survival period was 26 weeks after first diagnosis." + ], + "summary": "A 10-year-old Kurdish boy was presented with generalized bone pain and fever of 1 month's duration which was associated with sweating, easy fatigability, nose bleeding, breathlessness and severe weight loss. On examination, we observed pallor, tachypnea, tachycardia, low blood pressure, fever, petechial hemorrhage, ecchymoses, tortuous dilated veins over the chest and upper part of abdomen, multiple small cervical lymph node enlargements, mildly enlarged spleen, palpable liver and gross abdominal distention. Blood analysis revealed pancytopenia and elevated lactate dehydrogenase and erythrocyte sedimentation rate. Imaging results showed mediastinal widening on a planar chest X-ray and diffuse focal infiltration of the axial bone marrow on magnetic resonance imaging of the lumbosacral vertebrae. Bone marrow aspiration and biopsy examination showed extensive bone marrow necrosis. Immunophenotyping analysis of the bone marrow biopsy confirmed T-cell acute lymphoblastic leukemia, as CD3 and terminal deoxynucleotidyl transferase markers were positive and CD10, CD20 and CD79a markers were negative.", + "summary_subclaims": [ + "The patient is a 10-year-old Kurdish boy.", + "He had generalized bone pain and fever of 1 month's duration.", + "The fever was associated with sweating.", + "The fever was associated with easy fatigability.", + "The fever was associated with nose bleeding.", + "The fever was associated with breathlessness.", + "The fever was associated with severe weight loss.", + "On examination, pallor was observed.", + "On examination, tachypnea was observed.", + "On examination, tachycardia was observed.", + "On examination, low blood pressure was observed.", + "On examination, fever was observed.", + "On examination, petechial hemorrhage was observed.", + "On examination, ecchymoses were observed.", + "On examination, tortuous dilated veins over the chest and upper part of abdomen were observed.", + "On examination, multiple small cervical lymph node enlargements were observed.", + "On examination, a mildly enlarged spleen was observed.", + "On examination, a palpable liver was observed.", + "On examination, gross abdominal distention was observed.", + "Blood analysis revealed pancytopenia.", + "Blood analysis revealed elevated lactate dehydrogenase.", + "Blood analysis revealed elevated erythrocyte sedimentation rate.", + "Imaging results showed mediastinal widening on a planar chest X-ray.", + "Imaging results showed diffuse focal infiltration of the axial bone marrow on magnetic resonance imaging of the lumbosacral vertebrae.", + "Bone marrow aspiration and biopsy examination showed extensive bone marrow necrosis.", + "Immunophenotyping analysis of the bone marrow biopsy confirmed T-cell acute lymphoblastic leukemia.", + "CD3 markers were positive.", + "Terminal deoxynucleotidyl transferase markers were positive.", + "CD10 markers were negative.", + "CD20 markers were negative.", + "CD79a markers were negative." + ] + }, + { + "id": "multiclinsum_test_285_en.txt", + "fulltext": "A 26-year-old Asian man was transported to the emergency department via ambulance due to bilateral lower limb weakness. He had no relevant medical history except for a diagnosis of aseptic meningitis more than 10 years ago without sequelae. The patient was a construction worker who performed heavy labor. He stated that he had suffered from intermittent muscle cramping over the right shoulder radiating to back for a week, and he visited a local traditional medicine practitioner a day before the emergency department visit. Non-steroidal anti-inflammatory drugs and another unknown agent were injected. The muscle cramping improved before he slept. However, acute limb weakness occurred after the patient woke up in the morning. He had difficulty standing and fell, resulting in upper limb contusions.\nUpon arrival at our emergency department, the tympanic membrane temperature was 38.1°C, with normotension and no other abnormalities in vital signs. In addition, a review of the system showed no loss of consciousness, limb or trunk pain, upper respiratory symptoms, vomiting, diarrhea, or heavy sweating. He had no regular consumption of alcohol or smoking habits, and his family history included only hypertension and diabetes mellitus of his grandparents, without diseases related to hypokalemia or muscle weakness.\nThe patient was oriented with a good mental health status and appeared to be well nourished. Physical examination showed decreased muscle power of the bilateral lower limbs, mainly proximal, and both scored 2/5, which progressed to 1/5. The deep tendon reflex of the bilateral knees and sensation of the lower limbs were intact, and the muscle power of the upper limbs was not affected. There was also no Babinski sign elicited on either side. Blood tests, including complete cell count, blood sugar, and a biochemical panel, were normal, except for white blood cells (10,800/μL), potassium (1.7 mEq/L), and creatine phosphokinase (178 U/L). Urinalysis was normal. However, electrocardiogram showed a flattened T wave and exhibited U waves in the precordial leads V1–V3.\nOral and intravenous potassium supplements with 40 mEq was administered, and the serum potassium level result was still 2.0 mEq/L the following morning. We then administered another 60 mEq of potassium, and upon assessment, the muscle power of the patient’s bilateral lower limbs improved in the afternoon (4/5). He was admitted to the ward and was administered an additional 20 mEq of intravenous potassium (a total of 120 mEq since the emergency department); hypokalemia resolved (serum potassium 4.0 mEq/L), and the patient could walk steadily. Because his paralysis improved rapidly after hypokalemia correction and myopathies were less likely, electromyography was not done during admission.\nThe urinary potassium excretion of the patient was low (urine potassium/creatinine ratio is 1.5 mmol/mmol) and there was no evidence of potassium loss from gastrointestinal tract. He also denied potassium-shifting or potassium-wasting medication use, such as insulin, beta-agonists, thyroxine, or diuretics. The levels of serum aldosterone (109.5 pg/mL), renin (34.98 pg/mL), and free T4 (1.14 ng/dL) were borderline normal; however, elevated levels of serum thyroid stimulating hormone (TSH) (5.91 uIU/mL) were noted. Arterial blood gas analysis was normal. Hypokalemic periodic paralysis was considered as the clinical impression because of rapid normalization of potassium levels and improvement of weakness. However, the patient did not receive further genetic tests due to personal reasons.\nFurthermore, the patient denied having much carbohydrate-rich food intake or strenuous exercise before the attack. His family contacted the local clinic which disclosed that it had administered 5 mg dexamethasone through intramuscular injection. His serum cortisol level was <1.00 μg/dL and 4.39 μg/dL at 2 and 4 days after the injection, respectively. The final diagnosis was HPP of the non-familial type, suspected to be induced by dexamethasone injection. Finally, he was discharged without further sequela.\nOne year later, he came back to our emergency department due to hypokalemia-induced paralysis after eating a big carbohydrate-rich meal. We advised him to avoid using corticosteroids and eating carbohydrate-rich food.", + "fulltext_subclaims": [ + "The patient was a 26-year-old Asian man.", + "He was transported to the emergency department via ambulance due to bilateral lower limb weakness.", + "He had no relevant medical history except for a diagnosis of aseptic meningitis more than 10 years ago without sequelae.", + "The patient was a construction worker who performed heavy labor.", + "He had suffered from intermittent muscle cramping over the right shoulder radiating to back for a week.", + "He visited a local traditional medicine practitioner a day before the emergency department visit.", + "Non-steroidal anti-inflammatory drugs and another unknown agent were injected.", + "The muscle cramping improved before he slept.", + "Acute limb weakness occurred after the patient woke up in the morning.", + "He had difficulty standing and fell, resulting in upper limb contusions.", + "Upon arrival at the emergency department, the tympanic membrane temperature was 38.1°C.", + "He had no regular consumption of alcohol or smoking habits.", + "His family history included only hypertension and diabetes mellitus of his grandparents.", + "Physical examination showed decreased muscle power of the bilateral lower limbs, mainly proximal, and both scored 2/5.", + "The deep tendon reflex of the bilateral knees and sensation of the lower limbs were intact.", + "The muscle power of the upper limbs was not affected.", + "There was no Babinski sign elicited on either side.", + "Blood tests showed potassium of 1.7 mEq/L.", + "Electrocardiogram showed a flattened T wave and exhibited U waves in the precordial leads V1–V3.", + "Oral and intravenous potassium supplements with 40 mEq was administered.", + "The serum potassium level result was still 2.0 mEq/L the following morning.", + "We then administered another 60 mEq of potassium.", + "The muscle power of the patient’s bilateral lower limbs improved in the afternoon (4/5).", + "He was admitted to the ward and was administered an additional 20 mEq of intravenous potassium.", + "Hypokalemia resolved (serum potassium 4.0 mEq/L), and the patient could walk steadily.", + "The urinary potassium excretion of the patient was low (urine potassium/creatinine ratio is 1.5 mmol/mmol).", + "There was no evidence of potassium loss from gastrointestinal tract.", + "The patient denied potassium-shifting or potassium-wasting medication use.", + "Elevated levels of serum thyroid stimulating hormone (TSH) (5.91 uIU/mL) were noted.", + "Hypokalemic periodic paralysis was considered as the clinical impression.", + "The patient did not receive further genetic tests due to personal reasons.", + "The patient denied having much carbohydrate-rich food intake or strenuous exercise before the attack.", + "The local clinic disclosed that it had administered 5 mg dexamethasone through intramuscular injection.", + "The final diagnosis was HPP of the non-familial type, suspected to be induced by dexamethasone injection.", + "He was discharged without further sequela.", + "One year later, he came back to our emergency department due to hypokalemia-induced paralysis after eating a big carbohydrate-rich meal.", + "We advised him to avoid using corticosteroids and eating carbohydrate-rich food." + ], + "summary": "Here, we present the case of a 26-year-old Asian man who suffered from an acute onset of bilateral lower limb weakness with hypokalemia following dexamethasone injection. He was diagnosed with HPP.", + "summary_subclaims": [ + "The patient is a 26-year-old Asian man.", + "He suffered from an acute onset of bilateral lower limb weakness.", + "He had hypokalemia following a dexamethasone injection.", + "He was diagnosed with HPP." + ] + }, + { + "id": "multiclinsum_test_1130_en.txt", + "fulltext": "A 43-year-old female presented to the Department of Neurology of the Second Affiliated Hospital of Zhejiang University in March 2021. She was diagnosed with WD 12 years ago. Physical examination showed the patient had reduced facial expression and impaired articulation. The patient's left hand mildly trembled when she was asked to raise it flatly. She was also found to have increased extremity muscular tension, upper extremity tendon reflex +++++, and was unable to walk straight. Laboratory tests showed a low ceruloplasmin level (23 mg/L, reference 200–600 mg/L), and no abnormal serum copper concentration was found. Skull MRI showed hepatolenticular degeneration. Abdominal ultrasound revealed liver cirrhosis and splenomegaly. The patient was hospitalized and given sodium dimercaptopropane sulfonate for copper removal, zinc gluconate to inhibit copper metabolism, and supportive treatment such as amantadine and vitamin C supplements. During hospitalization, the patient complained of progressive bilateral vision decrease over 10 years, for which she was referred to our Eye Center. She volunteered that the night blindness began in early childhood, and her parents were close relatives. Her parents and sister were healthy, denying a similar medical history. The patient's best corrected visual acuity (BCVA) at presentation was 0.8 (logarithm of the minimum angle of resolution, logMAR) in both eyes, and intraocular pressure (Non-contact tonometer, Topcon CT-80, Topcon Corporation, Tokyo, Japan) was 10.0 mmHg in the right eye (OD) and 13.5 mmHg in the left eye (OS), respectively. Slit lamp biomicroscopy (SL-D8Z; Topcon Corporation, Tokyo, Japan) revealed bilateral corneal K-F ring and sunflower-like cataract . Fundus photography (TRC-NW8; Topcon Corporation, Tokyo, Japan) showed thinner retinal blood vessels and retinal osteocyte-like pigmentation in bilateral eyes . Cystoid macular edema (CME) and outer retina atrophy was observed in both eyes via optical coherence tomography (OCT) . Visual field examination (Octopus 900, Haag-Streit, USA) revealed binocular tunnel vision . The patient was subsequently diagnosed with WD combined with binocular RP and complicated cataract.\nAfter informed consent form the patient, phacoemulsification and posterior chamber intraocular lens implantation was performed in the right and left eye, respectively. Postoperatively, topical Tobradex (Tobramycin and Dexamethasone, Alcon) and Pranoprofen (Senju Pharmaceutical Co.Ltd, Japan) eyedrops were prescribed four times a day for anti-inflammatory treatment. Drug therapy for CME was not started before the surgery, and there was no significant change in the central retinal thickness (CRT) of both eyes during the 8-months follow-up. Unfortunately, there was limited improvement in her visual acuity. The BCVA remains 0.8 logMAR for both eyes at her last visit .\nWhole exome sequencing (WES, by Beijing Giantmed medical diagnostics Lab) was performed on the patient and her parents . The results showed an ATP7B gene c.G2333T: p.R778L homozygous mutation, CNGA1 gene c.C453A: p.Y151X homozygous mutation, RP2 gene c.T248C: p.l83T heterozygous mutation, and SNRNP200 gene c.C1898T: p.A633V heterozygous mutation in the patient . Both parents were heterozygous carriers of ATP7B and CNGA1 genes. The mother was of the RP2 heterozygous genotype, and the father was of the SNRNP200 heterozygous genotype, which were both found in the patient. However, the parents did not show any WD or RP-related manifestations.", + "fulltext_subclaims": [ + "The patient was diagnosed with WD 12 years ago.", + "Physical examination showed the patient had reduced facial expression and impaired articulation.", + "The patient's left hand mildly trembled when she was asked to raise it flatly.", + "She was found to have increased extremity muscular tension.", + "She was found to have upper extremity tendon reflex +++++.", + "She was unable to walk straight.", + "Laboratory tests showed a low ceruloplasmin level (23 mg/L).", + "Skull MRI showed hepatolenticular degeneration.", + "Abdominal ultrasound revealed liver cirrhosis.", + "Abdominal ultrasound revealed splenomegaly.", + "The patient was given sodium dimercaptopropane sulfonate for copper removal.", + "The patient was given zinc gluconate to inhibit copper metabolism.", + "The patient was given amantadine and vitamin C supplements.", + "The patient complained of progressive bilateral vision decrease over 10 years.", + "The patient's best corrected visual acuity at presentation was 0.8 in both eyes.", + "Slit lamp biomicroscopy revealed bilateral corneal K-F ring.", + "Slit lamp biomicroscopy revealed sunflower-like cataract.", + "Fundus photography showed thinner retinal blood vessels.", + "Fundus photography showed retinal osteocyte-like pigmentation in bilateral eyes.", + "Optical coherence tomography showed cystoid macular edema in both eyes.", + "Optical coherence tomography showed outer retina atrophy in both eyes.", + "Visual field examination revealed binocular tunnel vision.", + "The patient was diagnosed with WD combined with binocular RP.", + "The patient was diagnosed with complicated cataract.", + "Phacoemulsification and posterior chamber intraocular lens implantation was performed in the right eye.", + "Phacoemulsification and posterior chamber intraocular lens implantation was performed in the left eye.", + "Postoperatively, topical Tobradex eyedrops were prescribed four times a day.", + "Postoperatively, topical Pranoprofen eyedrops were prescribed four times a day.", + "Drug therapy for CME was not started before the surgery.", + "There was no significant change in the central retinal thickness during the 8-months follow-up.", + "The BCVA remained 0.8 logMAR for both eyes at the last visit.", + "Whole exome sequencing was performed on the patient and her parents.", + "The patient had an ATP7B gene c.G2333T: p.R778L homozygous mutation.", + "The patient had a CNGA1 gene c.C453A: p.Y151X homozygous mutation.", + "The patient had an RP2 gene c.T248C: p.l83T heterozygous mutation.", + "The patient had a SNRNP200 gene c.C1898T: p.A633V heterozygous mutation.", + "Both parents were heterozygous carriers of ATP7B and CNGA1 genes.", + "The mother was of the RP2 heterozygous genotype.", + "The father was of the SNRNP200 heterozygous genotype.", + "The parents did not show any WD or RP-related manifestations." + ], + "summary": "The patient was a 43-year-old Chinese female diagnosed with WD 12 years ago. She had suffered from night blindness since childhood and faced diminution of bilateral vision within 10 years, for which she was referred to our Eye Center during hospitalization for routine copper excretion treatment. The ceruloplasmin, skull magnetic resonance imaging (MRI), and abdominal ultrasound results accorded with hepatolenticular degeneration. Ocular examinations revealed corneal Kayser-Fleischer (K-F) ring, sunflower-like cataract, retinal osteocyte-like pigmentation, bilateral atrophy of outer retina, cystoid macular edema (CME), and tubular vision in both eyes. Phacoemulsification combined with intraocular lens implantation was performed in the right and left eye, but there was limited improvement in her visual acuity. Whole exome sequencing (WES) detected a deleterious homozygous mutation in the ATP7B gene related to WD, and a homozygous mutation in the CNGA1 gene very likely to cause RP.", + "summary_subclaims": [ + "The patient was a 43-year-old Chinese female.", + "She was diagnosed with WD 12 years ago.", + "She had suffered from night blindness since childhood.", + "She faced diminution of bilateral vision within 10 years.", + "She was referred to the Eye Center during hospitalization for routine copper excretion treatment.", + "The ceruloplasmin, skull MRI, and abdominal ultrasound results accorded with hepatolenticular degeneration.", + "Ocular examinations revealed corneal Kayser-Fleischer (K-F) ring.", + "Ocular examinations revealed sunflower-like cataract.", + "Ocular examinations revealed retinal osteocyte-like pigmentation.", + "Ocular examinations revealed bilateral atrophy of outer retina.", + "Ocular examinations revealed cystoid macular edema (CME).", + "Phacoemulsification combined with intraocular lens implantation was performed in the right and left eye.", + "There was limited improvement in her visual acuity.", + "Whole exome sequencing (WES) detected a deleterious homozygous mutation in the ATP7B gene related to WD.", + "WES detected a homozygous mutation in the CNGA1 gene very likely to cause RP." + ] + }, + { + "id": "multiclinsum_test_757_en.txt", + "fulltext": "A 49-year-old male patient from Kenya presented at the thyroid surgery outpatient clinic of our institution (Hamad General Hospital, largest tertiary facility in Doha, Qatar), in July 2021. He presented with a painless neck swelling associated with compression symptoms in the form of difficult swallowing and choking since about 3 months. He had a history of hypothyroidism and was on levothyroxine. Upon physical examination, there was a hugely diffuse non-tender goiter, with no lymphadenopathy. The vitals were normal, and systems examination was unremarkable. There were no palpitations, no shortness of breath, cough, or wheezing. Family history was unremarkable. He was a current smoker.\nUltrasound (US) of the thyroid showed large right and left thyroid lobes (43.6 and 44.1 mm in maximal antero-posterior dimension respectively). There was a hypoechoic nodule (8 × 7 × 8 mm), and lymph nodes were noted, the largest at the right upper cervical region measuring 8.4 × 6.4 mm. Another lymph node was seen superior to the isthmus measuring 17 × 9 mm. These features suggested thyroiditis (, ). FNAC of the right thyroid nodule showed scant follicular cells, abundant polymorphic lymphocytes, epithelioid histiocytes, tingible body macrophages and some colloid, suggestive of De Quervain's (granulomatous) thyroiditis . The patient was started on conservative treatment for 2 months. The patient improved but the compression symptoms recurred, and total thyroidectomy was scheduled due to the gland's size, disfigurement of the neck, and the compression symptoms. This was discussed with the patient who agreed to the plan, and it was scheduled.", + "fulltext_subclaims": [ + "The patient is a 49-year-old male.", + "The patient is from Kenya.", + "The patient presented at the thyroid surgery outpatient clinic of Hamad General Hospital.", + "The patient presented in July 2021.", + "The patient had a painless neck swelling.", + "The patient had compression symptoms in the form of difficult swallowing and choking.", + "The symptoms had been present for about 3 months.", + "The patient had a history of hypothyroidism.", + "The patient was on levothyroxine.", + "Upon physical examination, there was a hugely diffuse non-tender goiter.", + "There was no lymphadenopathy.", + "The vitals were normal.", + "There were no palpitations.", + "There was no shortness of breath.", + "There was no wheezing.", + "The family history was unremarkable.", + "The patient was a current smoker.", + "Ultrasound of the thyroid showed large right and left thyroid lobes.", + "The right thyroid lobe measured 43.6 mm in maximal antero-posterior dimension.", + "The left thyroid lobe measured 44.1 mm in maximal antero-posterior dimension.", + "There was a hypoechoic nodule measuring 8 × 7 × 8 mm.", + "A lymph node was noted at the right upper cervical region measuring 8.4 × 6.4 mm.", + "Another lymph node was seen superior to the isthmus measuring 17 × 9 mm.", + "These features suggested thyroiditis.", + "FNAC of the right thyroid nodule showed scant follicular cells.", + "FNAC showed abundant polymorphic lymphocytes.", + "FNAC showed epithelioid histiocytes.", + "FNAC showed tingible body macrophages.", + "FNAC showed some colloid.", + "FNAC was suggestive of De Quervain's (granulomatous) thyroiditis.", + "The patient was started on conservative treatment for 2 months.", + "The patient improved after conservative treatment.", + "The compression symptoms recurred.", + "Total thyroidectomy was scheduled.", + "The reason for scheduling total thyroidectomy was the gland's size.", + "The reason for scheduling total thyroidectomy was disfigurement of the neck.", + "The reason for scheduling total thyroidectomy was the compression symptoms.", + "The patient agreed to the plan.", + "The surgery was scheduled." + ], + "summary": "Patient with history of hypothyroidism presented with huge non-tender goiter, compression symptoms and choking, no lymphadenopathy. Ultrasound (US) showed large thyroid lobes. There was a small hypoechoic nodule, and nonspecific lymphadenopathy. Fine needle aspiration/cytology (FNAC) of right thyroid nodule showed scant follicular cells, abundant polymorphic lympocytes, epithelioid histiocytes, and tingible body macrophages, suggestive of De Quervain's (granulomatous) thyroiditis. Total thyroidectomy was decided due to compression symptoms and huge goiter.", + "summary_subclaims": [ + "The patient has a history of hypothyroidism.", + "The patient presented with a huge non-tender goiter.", + "The patient had compression symptoms and choking.", + "There was no lymphadenopathy on presentation.", + "Ultrasound showed large thyroid lobes.", + "Ultrasound showed a small hypoechoic nodule.", + "Ultrasound showed nonspecific lymphadenopathy.", + "Fine needle aspiration/cytology of the right thyroid nodule showed scant follicular cells.", + "Fine needle aspiration/cytology showed abundant polymorphic lymphocytes.", + "Fine needle aspiration/cytology showed epithelioid histiocytes.", + "Fine needle aspiration/cytology showed tingible body macrophages.", + "The findings were suggestive of De Quervain's (granulomatous) thyroiditis.", + "Total thyroidectomy was decided due to compression symptoms and huge goiter." + ] + }, + { + "id": "multiclinsum_test_2431_en.txt", + "fulltext": "A 42-year-old right-handed woman suffered from weekly repetitions of unconscious dancing for 5 years, despite of multiple antiepileptic drugs including levetiracetam 3000 mg/d, valproate 900 mg/d, and pregabalin 300 mg/d. She was admitted to the epilepsy monitoring unit of a tertiary referral center for the feasibility of epilepsy surgery. On the initial clinical examination, she had no other symptoms or signs. The routine laboratory tests were negative. Magnetic resonance imaging showed right hippocampal atrophy . Her habitual seizure was recorded during video-electroencephalography monitoring. The seizure began with the right hand automatism and ictal speech, which suggest that the ictal onset zone would be on the right side. An evolution of rhythmic delta activity was observed in the right temporal area beginning 16 s after the automatism (see Additional file 1: Video S1). As the ictal discharge spreads to the left temporal area, which means the secondary generalization, the ictal speech disappeared. After 20 s from the secondary generalization, she had rhythmical movement of her legs, similar to stepping through a dance, and the simultaneous video-electroencephalography showed regional slow waves over both of her frontal areas. When the ictal rhythm has switched to the left side, the left upper limb automatism and immobility of the right upper limb represented the rhythmic theta activity, which is still seen in the left temporal area. Taken together, we could identify the kicking and stepping like a dance as well as shaking left arm. According to her husband, the movement would have involved twirling dance, making a right turn when she was standing. However, it was not shown on the video. The dancing lasted even after the rhythmic discharge, which definitized the post-ictal dancing. We surmise that the “dancing” movement might be derived from some combination of automatism consisted of complex, rhythmic, and sequencial movement. She was completely amnestic with respect to the episode. Her ictal speech and the ictal electroencephalography imply that the right hippocampus atrophy should be the epileptogenic focus. There has been only one seizure for 3 months since a stereotactic gamma knife surgery applied to the atrophic right hippocampus.\nThe authors declare that they adhered to CARE guidelines/methodology.", + "fulltext_subclaims": [ + "The patient is a 42-year-old right-handed woman.", + "She had weekly repetitions of unconscious dancing for 5 years.", + "She was taking levetiracetam 3000 mg/d.", + "She was taking valproate 900 mg/d.", + "She was taking pregabalin 300 mg/d.", + "She was admitted to the epilepsy monitoring unit of a tertiary referral center.", + "The admission was for the feasibility of epilepsy surgery.", + "The routine laboratory tests were negative.", + "Magnetic resonance imaging showed right hippocampal atrophy.", + "Her habitual seizure was recorded during video-electroencephalography monitoring.", + "The seizure began with the right hand automatism.", + "The seizure began with ictal speech.", + "The ictal speech suggests that the ictal onset zone would be on the right side.", + "Rhythmic delta activity was observed in the right temporal area.", + "The rhythmic delta activity began 16 s after the automatism.", + "The ictal discharge spread to the left temporal area.", + "The ictal discharge spreading to the left temporal area means secondary generalization.", + "The ictal speech disappeared after the ictal discharge spread to the left temporal area.", + "After 20 s from the secondary generalization, she had rhythmical movement of her legs.", + "The rhythmical movement of her legs was similar to stepping through a dance.", + "Regional slow waves over both frontal areas were observed.", + "When the ictal rhythm switched to the left side, the left upper limb automatism represented rhythmic theta activity.", + "The right upper limb immobility represented rhythmic theta activity.", + "The rhythmic theta activity was still seen in the left temporal area.", + "The kicking and stepping like a dance were identified.", + "The shaking left arm was identified.", + "According to her husband, the movement would have involved twirling dance.", + "According to her husband, the movement would have involved making a right turn when she was standing.", + "The twirling dance was not shown on the video.", + "The dancing lasted even after the rhythmic discharge.", + "The post-ictal dancing was definitized.", + "The authors surmise that the “dancing” movement might be derived from some combination of automatism.", + "The automatism consisted of complex, rhythmic, and sequential movement.", + "She was completely amnestic with respect to the episode.", + "Her ictal speech and the ictal electroencephalography imply that the right hippocampus atrophy should be the epileptogenic focus.", + "A stereotactic gamma knife surgery was applied to the atrophic right hippocampus.", + "There has been only one seizure for 3 months since the surgery.", + "The authors adhered to CARE guidelines/methodology." + ], + "summary": "A 42-year-old woman with medical intractable epilepsy showed a typical semiology of right temporal lobe epilepsy: right hand automatism and ictal speech. The following semiology, appeared during ictal and post-ictal stage, was complex, rhythmical and sequential movement. It was enough to be called dancing.", + "summary_subclaims": [ + "The patient is a 42-year-old woman.", + "The patient has medical intractable epilepsy.", + "The patient showed a typical semiology of right temporal lobe epilepsy.", + "The semiology included right hand automatism.", + "The semiology included ictal speech.", + "The following semiology appeared during ictal and post-ictal stage.", + "The semiology was complex, rhythmical and sequential movement.", + "It was enough to be called dancing." + ] + }, + { + "id": "multiclinsum_test_2002_en.txt", + "fulltext": "An 18-year-old man (175 cm, 81 kg) with right hemifacial microsomia was scheduled for double-jaw surgery, correction with distraction osteogenesis, and mandibular anglectomy. Although he had no underlying medical history, he had undergone correction with distraction osteogenesis in 2006. At that time, the patient was classified as Cormack-Lehane grade 4, and oral intubation was performed with FOB. The patient reported a history of sleep apnea and heavy snoring, during the preoperative interview. His mouth opening was about 2.5-finger-breadth and neck extension was normal, during the preoperative physical examination. However, he had severe retrognathia and a class III Mallampati score. The thyromental distance was less than 6 cm. Moreover, an oral panoramic view X-ray showed narrowing of the nasopharyngeal airway, due to severe retrognathia . According to El-Anwar et al. , the mean depth (anteroposterior diameter) of the nasopharynx in normal adults is 21.8 ± 4.6 mm. However, the depth of nasopharynx in our patient was 15.5 mm, which was narrower than usual. We explained the possibility of a difficult airway and informed the patient about the special risks and procedures pertaining to performing an awake intubation procedure. Other preoperative laboratory examinations, chest X-ray, and electrocardiography revealed no abnormalities.\nOn the day of surgery, we prepared a Glidescope®; LMA, fiberoptic bronchoscope (Olympus Optical, Japan); a 0.035-inch-thick, 145-cm-long straight-tipped Angio Guidewire (Lunderquist-ring, Cook Critical Care, ); and a high-flow nasal cannula (Optiflow™). Nasotracheal intubation was required to secure space in the oral cavity for surgery; thus, we prepared nasotracheal tubes of various sizes. Non-invasive blood pressure monitoring, electrocardiogram, pulse oximetry, and bispectral index (BIS) measurement were performed in the operating room. The monitor showed an initial blood pressure of 140/84 mmHg, a heart rate of 58 beats/min and room air saturation of 98%. Lidocaine 4% was sprayed onto the tongue and oropharynx for topical anesthesia. Sufficient preoxygenation was provided with Optiflow™, at a flow rate of 20 L/min, to achieve an SpO2 of 100%. We started total intravenous anesthesia (TIVA) with 2% propofol and remifentanil administered at effect-site concentrations of 2.5 µg/ml and 1.5 ng/ml, respectively, with a target-controlled infusion pump. The SpO2 decreased to 96%, soon after the BIS was 42 and the patient fell asleep, but there was no further desaturation, after we raised the flow rate of Optiflow™ to 40 L/min. Since the left nostril was larger than the right nostril, owing to right-sided hemifacial microsomia, we decided to insert the FOB into the left nostril. After guiding the FOB into the left nostril of the patient, it passed into the trachea through the glottis, without any issue. We inserted the 145-cm-long, straight-tipped Angio Guidewire (Lunderquist-ring, Cook Critical Care) into the working channel of the FOB, till we could visualize the entrance of the guidewire into the carina . We carefully removed the FOB and the guidewire remained in position. We also used the Glidescope® to confirm that the guidewire was still within the oral cavity and had passed through the vocal cord, and into the trachea . The exchange catheter (1.6-mm internal diameter [ID], 2.7-mm outer diameter, CAEC, Cook Critical Care) was inserted over the Angio Guidewire and the Angio Guidewire was pulled out. A nasotracheal tube with 6.5 mm ID was advanced carefully over the exchange catheter into the airway without incidence. After removing the exchange catheter, the tracheal tube cuff was inflated, and proper positioning of the ETT was confirmed by auscultating both lungs and by confirming continuous positive end-tidal CO2. The monitor showed a blood pressure of 133/86 mmHg, heart rate of 95 beats/min, an SpO2 of 97%, and a BIS of 50 after intubation. An oxygenation level of 97% or higher was maintained throughout the procedure. After confirming proper intubation, we adjusted the effect-site concentration of propofol and remifentanil to 4.0 µg/ml and 2.5 µg/ml, respectively, and administered 80 mg of rocuronium intravenously. The time required for the administration of intubation to its confirmation was 16 min. The intra and postoperative periods were uneventful.\nAfter the procedure, we provided a full explanation regarding this case report to the patient and obtained permission for the same.", + "fulltext_subclaims": [ + "The patient was an 18-year-old man.", + "The patient was 175 cm tall.", + "The patient weighed 81 kg.", + "The patient had right hemifacial microsomia.", + "The patient was scheduled for double-jaw surgery.", + "The patient was scheduled for correction with distraction osteogenesis.", + "The patient was scheduled for mandibular anglectomy.", + "The patient had no underlying medical history.", + "The patient had undergone correction with distraction osteogenesis in 2006.", + "At that time, the patient was classified as Cormack-Lehane grade 4.", + "At that time, oral intubation was performed with FOB.", + "The patient reported a history of sleep apnea.", + "The patient reported heavy snoring.", + "The patient's mouth opening was about 2.5-finger-breadth.", + "The patient's neck extension was normal.", + "The patient had severe retrognathia.", + "The patient had a class III Mallampati score.", + "The thyromental distance was less than 6 cm.", + "An oral panoramic view X-ray showed narrowing of the nasopharyngeal airway.", + "The narrowing of the nasopharyngeal airway was due to severe retrognathia.", + "The mean depth of the nasopharynx in normal adults is 21.8 ± 4.6 mm.", + "The depth of the nasopharynx in the patient was 15.5 mm.", + "The depth of the nasopharynx in the patient was narrower than usual.", + "We explained the possibility of a difficult airway.", + "We informed the patient about the special risks and procedures pertaining to performing an awake intubation procedure.", + "Other preoperative laboratory examinations revealed no abnormalities.", + "A chest X-ray revealed no abnormalities.", + "An electrocardiogram revealed no abnormalities.", + "On the day of surgery, we prepared a Glidescope®.", + "On the day of surgery, we prepared an LMA.", + "On the day of surgery, we prepared a fiberoptic bronchoscope.", + "On the day of surgery, we prepared a 0.035-inch-thick, 145-cm-long straight-tipped Angio Guidewire.", + "On the day of surgery, we prepared a high-flow nasal cannula.", + "Nasotracheal intubation was required to secure space in the oral cavity for surgery.", + "We prepared nasotracheal tubes of various sizes.", + "Non-invasive blood pressure monitoring was performed.", + "An electrocardiogram was performed.", + "Pulse oximetry was performed.", + "Bispectral index measurement was performed.", + "The initial blood pressure was 140/84 mmHg.", + "The initial heart rate was 58 beats/min.", + "The initial room air saturation was 98%.", + "Lidocaine 4% was sprayed onto the tongue.", + "Lidocaine 4% was sprayed onto the oropharynx.", + "Sufficient preoxygenation was provided with Optiflow™.", + "The flow rate of Optiflow™ was 20 L/min.", + "We started total intravenous anesthesia with 2% propofol.", + "We started total intravenous anesthesia with remifentanil administered at an effect-site concentration of 1.5 ng/ml.", + "The SpO2 decreased to 96% soon after the BIS was 42.", + "The patient fell asleep soon after the BIS was 42.", + "There was no further desaturation after we raised the flow rate of Optiflow™ to 40 L/min.", + "The left nostril was larger than the right nostril.", + "The left nostril was larger due to right-sided hemifacial microsomia.", + "We decided to insert the FOB into the left nostril.", + "After guiding the FOB into the left nostril, it passed into the trachea through the glottis without any issue.", + "We inserted the 145-cm-long, straight-tipped Angio Guidewire into the working channel of the FOB.", + "We could visualize the entrance of the guidewire into the carina.", + "We carefully removed the FOB.", + "The guidewire remained in position.", + "We used the Glidescope® to confirm that the guidewire was still within the oral cavity.", + "We used the Glidescope® to confirm that the guidewire had passed through the vocal cord.", + "We used the Glidescope® to confirm that the guidewire had entered the trachea.", + "The exchange catheter was inserted over the Angio Guidewire.", + "The exchange catheter was 1.6-mm internal diameter.", + "The exchange catheter was 2.7-mm outer diameter.", + "The Angio Guidewire was pulled out.", + "A nasotracheal tube with 6.5 mm ID was advanced over the exchange catheter into the airway.", + "The tracheal tube cuff was inflated.", + "Proper positioning of the ETT was confirmed by auscultating both lungs.", + "Proper positioning of the ETT was confirmed by continuous positive end-tidal CO2.", + "The blood pressure after intubation was 133/86 mmHg.", + "The heart rate after intubation was 95 beats/min.", + "The SpO2 after intubation was 97%.", + "The BIS after intubation was 50.", + "An oxygenation level of 97% or higher was maintained throughout the procedure.", + "We adjusted the effect-site concentration of propofol to 4.0 µg/ml.", + "We adjusted the effect-site concentration of remifentanil to 2.5 ng/ml.", + "We administered 80 mg of rocuronium intravenously.", + "The time required for the administration of intubation to its confirmation was 16 min.", + "The intraoperative period was uneventful.", + "The postoperative period was uneventful.", + "After the procedure, we provided a full explanation regarding this case report to the patient.", + "After the procedure, we obtained permission for the case report from the patient." + ], + "summary": "An 18-year-old man with hemifacial microsomia was scheduled for double-jaw surgery. In preoperative evaluation, he had severe retrognathia and expected difficult airway. We successfully performed wire-guided fiberoptic nasotracheal intubation combined with high-flow nasal cannula and deep sedation without any complications.", + "summary_subclaims": [ + "The patient is an 18-year-old man.", + "The patient has hemifacial microsomia.", + "The patient was scheduled for double-jaw surgery.", + "In preoperative evaluation, he had severe retrognathia.", + "We successfully performed wire-guided fiberoptic nasotracheal intubation.", + "The intubation was combined with high-flow nasal cannula.", + "The intubation was combined with deep sedation.", + "The procedure was performed without any complications." + ] + }, + { + "id": "multiclinsum_test_2839_en.txt", + "fulltext": "A 60-year-old female had progressive HV and bunion deformities for many years. Despite increasing pain in the bunion area initially and then the crossover deformity between first and second toes, she could still manage for several years by wearing increasingly more accommodating shoes with wider forefoot region and roomy toe box made of soft materials. Due to her daily required walking activities, she developed thick and painful metatarsal calluses despite wearing mostly thick-soled shoes only. She could hardly tolerate the metatarsalgia of her feet in walking due to the constant feeling of walking on a pebble in her shoes. She found that walking was becoming an exhausting chore to avoid. She felt losing balance easily on uneven ground and walking down stairs. She had fallen several times already. Her mother had also HV deformity but not as severe and she got by without surgery. Physical examination revealed bilateral HV deformity that could only be partially corrected. The passive range of motion of her right foot first MPJ was 45° in both extension and flexion and 60° and 45°, respectively, of her left foot first MPJ. Her right second toe had severe varus deformity that was crossing over the hallux but without any remarkable clawing deformity. Her left second toe varus deformity was not as severe. The second toe varus deformity of her left foot could be manually realigned completely but not her right foot second toe. Both second MPJs were moderately tender and had reduced passive flexion movement due to pain. First metatarsals were hyper mobile in both sagittal and frontal planes. There were large and thick calluses under the forefoot region of both feet . Dorsoplantar standing x-rays of her feet revealed a right foot first intermetatarsal angle (IMA) of 17.5° and metatarsophalangeal angle (MPA) of 33.7° and 16.8° and 27.9°, respectively, of her left foot. IMA and MPA are usually considered normal within their upper limits of 9° and 15°, respectively. All first and second MPJs were incongruent and the right second MPJ subluxated in dorsomedial direction. Both tibial and fibula sesamoids were dissociated from their first metatarsals. Pre-operative walking plantar pressure study by F-Scan (Tekscan, USA) revealed poor weight bearing and reactive force under the first ray and obvious lateral shift of functional area of her forefeet to the second and third metatarsal heads where she had large and thick metatarsal calluses. This patient agreed to undergo a simultaneous bilateral syndesmosis procedure [, ], a non-osteotomy soft tissue technique, for her HV deformity correction and possible additional surgery and pinning if necessary for the varus deformity correction of her second toes.\nAn initial one-inch incision was made along the distal dorsal medial border of the second metatarsal. After blunt dissection, the interosseous muscle was retracted laterally and partially resected to help expose the lateral soft tissue structures for the release of the lateral collateral and metatarsosesamoid ligaments. The adductor hallucis tendon was preserved and the fibular sesamoid was not resected. The distal third of the first and second metatarsals was then exposed subperiosteally and roughened in a fish-scale fashion with an osteotome. Three drill holes of 2 mm diameter were made in dorsoplantar direction in the distal half of first metatarsal shaft about 5 mm apart. Double-strand number-onepolydioxanone dissolvable sutures (ETHICON, Johnson & Johnson, USA) were then passed through the drill holes and around the second metatarsal, binding the two together. Intraoperative anteroposterior (AP) view X-ray was then taken to assess the MPV deformity correction and first metatarsal alignment with a needle holder temporarily locking the intermetatarsal cerclage suture before it was tied later. However, to our surprise that, not only the HV and MPV deformities were corrected but also the severe right second toe varus deformity was also mostly corrected spontaneously without any surgical intervention to it yet. The same phenomenon also was happened to her left second toe but with complete spontaneous correction. The residual varus deformity of right foot second toe was then further corrected by capsulorrhaphy and collateral ligaments release of its MPJ. A medial horizontal elliptical incision was then made to remove redundant skin, bursa, capsular tissues, and exostoses. The combined single ligament tendon capsular layer was then approximated with interrupted 2-0 Vicryl sutures (Ethicon, Johnson & Johnson, USA) without plication.\nThe patient worea forefoot cast for protected walking for 3months. She was allowed only to return to unrestricted activities and shoes about 6months after surgery.", + "fulltext_subclaims": [ + "The patient is a 60-year-old female.", + "She had progressive hallux valgus and bunion deformities for many years.", + "She experienced increasing pain in the bunion area.", + "She could manage by wearing increasingly more accommodating shoes with wider forefoot region and roomy toe box made of soft materials.", + "She developed thick and painful metatarsal calluses despite wearing mostly thick-soled shoes.", + "She could hardly tolerate the metatarsalgia of her feet in walking due to the constant feeling of walking on a pebble in her shoes.", + "She felt losing balance easily on uneven ground and walking down stairs.", + "She had fallen several times already.", + "Her mother had hallux valgus deformity but not as severe and she got by without surgery.", + "Physical examination revealed bilateral hallux valgus deformity that could only be partially corrected.", + "The passive range of motion of her right foot first metatarsophalangeal joint was 45° in both extension and flexion.", + "The passive range of motion of her left foot first metatarsophalangeal joint was 60° and 45°, respectively.", + "Her right second toe had severe varus deformity that was crossing over the hallux but without any remarkable clawing deformity.", + "Her left second toe varus deformity was not as severe.", + "The second toe varus deformity of her left foot could be manually realigned completely.", + "The second toe varus deformity of her right foot could not be manually realigned.", + "Both second metatarsophalangeal joints were moderately tender.", + "Both second metatarsophalangeal joints had reduced passive flexion movement due to pain.", + "First metatarsals were hypermobile in both sagittal and frontal planes.", + "There were large and thick calluses under the forefoot region of both feet.", + "Dorsoplantar standing x-rays revealed a right foot first intermetatarsal angle of 17.5°.", + "Dorsoplantar standing x-rays revealed a right foot first metatarsophalangeal angle of 33.7°.", + "Dorsoplantar standing x-rays revealed a left foot first intermetatarsal angle of 16.8°.", + "Dorsoplantar standing x-rays revealed a left foot first metatarsophalangeal angle of 27.9°.", + "I intermetatarsal angle and metatarsophalangeal angle are usually considered normal within their upper limits of 9° and 15°, respectively.", + "All first and second metatarsophalangeal joints were incongruent.", + "The right second metatarsophalangeal joint subluxated in dorsomedial direction.", + "Both tibial and fibula sesamoids were dissociated from their first metatarsals.", + "Pre-operative walking plantar pressure study by F-Scan revealed poor weight bearing and reactive force under the first ray.", + "Pre-operative walking plantar pressure study by F-Scan revealed obvious lateral shift of functional area of her forefeet to the second and third metatarsal heads.", + "This patient agreed to undergo a simultaneous bilateral syndesmosis procedure.", + "The syndesmosis procedure is a non-osteotomy soft tissue technique.", + "An initial one-inch incision was made along the distal dorsal medial border of the second metatarsal.", + "After blunt dissection, the interosseous muscle was retracted laterally and partially resected.", + "The adductor hallucis tendon was preserved.", + "The fibular sesamoid was not resected.", + "The distal third of the first and second metatarsals was exposed subperiosteally and roughened in a fish-scale fashion with an osteotome.", + "Three drill holes of 2 mm diameter were made in dorsoplantar direction in the distal half of first metatarsal shaft about 5 mm apart.", + "Double-strand number-one polydioxanone dissolvable sutures were passed through the drill holes and around the second metatarsal, binding the two together.", + "Intraoperative anteroposterior view X-ray was taken to assess the MPV deformity correction and first metatarsal alignment.", + "The HV and MPV deformities were corrected.", + "The severe right second toe varus deformity was mostly corrected spontaneously without any surgical intervention.", + "The same phenomenon was happened to her left second toe with complete spontaneous correction.", + "The residual varus deformity of right foot second toe was further corrected by capsulorrhaphy and collateral ligaments release of its MPJ.", + "A medial horizontal elliptical incision was made to remove redundant skin, bursa, capsular tissues, and exostoses.", + "The combined single ligament tendon capsular layer was approximated with interrupted 2-0 Vicryl sutures.", + "The patient wore a forefoot cast for protected walking for 3 months.", + "She was allowed to return to unrestricted activities and shoes about 6 months after surgery." + ], + "summary": "A patient had bilateral HV and crossover deformities of her feet. She opted for a bilateral surgical treatment when conservation management failed to be helpful anymore. A soft tissue non-osteotomy technique called syndesmosis procedure was chosen for her deformities correction. Her crossover deformity was caused mainly by varus deformity of the second toe. Intraoperatively, the second toe varus deformity was found to correct itself spontaneously once the first metatarsal was realigned by a non-osteotomy intermetatarsal cerclage suture technique to correct the MPV deformity. Only themore severe second toe deformity of right foot required additional soft tissue release to help correct its mild residual varus deformity. The patient enjoyed excellent cosmetic and functional results. The possible pathogenesis of second toe varus deformity and its unexpected spontaneous correction is discussed.", + "summary_subclaims": [ + "The patient had bilateral HV and crossover deformities of her feet.", + "She opted for a bilateral surgical treatment when conservative management failed to be helpful anymore.", + "A soft tissue non-osteotomy technique called syndesmosis procedure was chosen for her deformities correction.", + "Her crossover deformity was caused mainly by varus deformity of the second toe.", + "Intraoperatively, the second toe varus deformity was found to correct itself spontaneously once the first metatarsal was realigned by a non-osteotomy intermetatarsal cerclage suture technique to correct the MPV deformity.", + "Only the more severe second toe deformity of right foot required additional soft tissue release to help correct its mild residual varus deformity.", + "The patient enjoyed excellent cosmetic and functional results.", + "The possible pathogenesis of second toe varus deformity and its unexpected spontaneous correction is discussed." + ] + }, + { + "id": "multiclinsum_test_1708_en.txt", + "fulltext": "A 19-year-old man developed blurry vision with new headaches in November 2014. He had bilateral papilledema. A MRI brain showed a large right-sided lesion involving the parieto-temporal lobes, hyperintense on T1 and T2-weighted sequences, with significant surrounding vasogenic edema on T2-weighted fluid-attenuated inversion recovery (FLAIR), contrast enhancement post-gadolinium, and a right-to-left midline shift . The overall appearance of this lesion looked a bit unusual for a classical GBM. He had a subtotal resection on January 30th, 2015, and was diagnosed by a local pathologist with a “GBM”. He completed 6 weeks of radiation therapy (RT) and temozolomide (TMZ). Four months later, a follow-up MRI showed an increase in the size of the enhancing tumor and, despite the possibility of pseudoprogression, a second surgical resection was performed on June 2nd, 2015 and showed “GBM”. Maintenance TMZ was started and follow-up imaging showed stable disease .\nThe patient was referred to the Neuro-Oncology clinic at MCC in June 2015. Histology review showed that he had a malignant PXA grade III–IV, rather than a GBM. It had multinucleated giant cells, prominent nucleoli, and eosinophilic granular bodies on 600 × HPF, and a high mitotic index with dysplastic neurons on 200 × HPF . Histological samples were GFAP positive, with necrosis, ATRX retained, had a proliferation rate of 2% by Ki-67, and was positive for BRAF V600E on IHC . Foundation one testing confirmed the BRAF V600E mutation, IDH1 wild-type, and no EGFRviii. Other testing showed that the tumor was negative for 1p/19q co-deletion and was O6-methylguanine-DNA methyltransferase (MGMT) promoter unmethylated.\nAfter an initial 17 months of stable disease, on his MRI, there was a small increase in the size of his tumor . Accordingly, combination therapy with BRAF kinase and MEK inhibitors, Dabrafenib 150 mg PO BID and Trametinib 2 mg PO OD, was started on November 2016. As soon as 2 months after starting treatment, there was radiographic evidence of disease regression, though it did not meet the criteria for a Partial Response because of its small size. The patient was continued on this treatment regimen for 10 months and further serial imaging showed stable disease.\nAfter 8 months of treatment, in July 2017, treatment was held to give the patient a “drug holiday,” but, 2 months later, his MRI showed disease progression. Dabrafenib and Trametinib were re-started, and he remained stable until January 2018 when he had disease progression with BRAF MEKi. Since resistance to BRAF inhibition can be overcome by autophagy inhibition [–], we added the autophagy inhibitor chloroquine (500 mg PO daily) to his BRAF MEKi therapy. Each tablet of chloroquine contains 500 mg of chloroquine phosphate USP and the equivalent to 300 mg chloroquine base, which is the standard, maximal safe dose that is FDA-approved for adults .\nBased on the Response Assessment in Neuro-Oncology (RANO) criteria, the lesion size was measured, the sum of the perpendicular diameters (SPD) calculated and plotted . The tumor decreased by more than 25% after BRAF MEKi was started but unfortunately increased after a drug holiday , and continued to grow despite re-starting therapy with BRAF MEKi , at which point the autophagy inhibitor chloroquine was added halting the rate of tumor progression and even causing a slight decrease in the lesion size .\nThere are no reported potential interactions between chloroquine and Dabrafenib and/or Trametinib. Chloroquine’s adverse effects can be multisystemic affecting the eyes (e.g., retinopathy, visual disturbances), hearing, liver, gastrointestinal system (e.g., nausea, vomiting, diarrhea, abdominal cramps), muscles (e.g., myopathy), skin (e.g., erythema multiforme, Stevens–Johnson syndrome), cardiac (e.g., prolonged QT interval), hematologic system (e.g., pancytopenia), and nervous system (e.g., seizures, extrapyramidal signs) . Given these side effects, we had taken precautionary measures with close monitoring every 1–2 months since started triple therapy, checking complete blood cells counts, complete metabolic panels, electrocardiogram, and echocardiograms. Overall, our patient tolerated the triple therapy well for 17 months until recently, when he complained of mild nausea, diarrhea, and a skin rash. The decision was made to hold chloroquine, while continuing Dabrafenib and Trametinib, with plans to re-assess him in 2 months.\nIn summary, radiographically, he has had Stable Disease with BRAF MEKi for 14 months, and later with the addition of chloroquine for a total of > 2.5 years of treatment (triple therapy for 17 months), without major side effects from the treatment, until recently for which he is receiving a drug holiday from chloroquine.", + "fulltext_subclaims": [ + "A 19-year-old man developed blurry vision with new headaches in November 2014.", + "He had bilateral papilledema.", + "A MRI brain showed a large right-sided lesion involving the parieto-temporal lobes.", + "The lesion was hyperintense on T1 and T2-weighted sequences.", + "There was significant surrounding vasogenic edema on T2-weighted fluid-attenuated inversion recovery (FLAIR).", + "The lesion showed contrast enhancement post-gadolinium.", + "There was a right-to-left midline shift.", + "The overall appearance of this lesion looked a bit unusual for a classical GBM.", + "He had a subtotal resection on January 30th, 2015.", + "He was diagnosed by a local pathologist with a “GBM.”", + "He completed 6 weeks of radiation therapy (RT) and temozolomide (TMZ).", + "Four months later, a follow-up MRI showed an increase in the size of the enhancing tumor.", + "A second surgical resection was performed on June 2nd, 2015.", + "Maintenance TMZ was started.", + "Follow-up imaging showed stable disease.", + "The patient was referred to the Neuro-Oncology clinic at MCC in June 2015.", + "Histology review showed that he had a malignant PXA grade III–IV, rather than a GBM.", + "Histological samples were GFAP positive.", + "The tumor had necrosis.", + "ATRX was retained.", + "The proliferation rate was 2% by Ki-67.", + "The tumor was positive for BRAF V600E on IHC.", + "Foundation one testing confirmed the BRAF V600E mutation.", + "The tumor was IDH1 wild-type.", + "The tumor was negative for EGFRviii.", + "The tumor was negative for 1p/19q co-deletion.", + "The tumor was O6-methylguanine-DNA methyltransferase (MGMT) promoter unmethylated.", + "After an initial 17 months of stable disease, on his MRI, there was a small increase in the size of his tumor.", + "Combination therapy with BRAF kinase and MEK inhibitors, Dabrafenib 150 mg PO BID and Trametinib 2 mg PO OD, was started on November 2016.", + "As soon as 2 months after starting treatment, there was radiographic evidence of disease regression.", + "The radiographic evidence of disease regression did not meet the criteria for a Partial Response because of its small size.", + "The patient was continued on this treatment regimen for 10 months.", + "Further serial imaging showed stable disease.", + "After 8 months of treatment, in July 2017, treatment was held to give the patient a “drug holiday.”", + "Two months later, his MRI showed disease progression.", + "Dabrafenib and Trametinib were re-started.", + "He remained stable until January 2018 when he had disease progression with BRAF MEKi.", + "Each tablet of chloroquine contains 500 mg of chloroquine phosphate USP and the equivalent to 300 mg chloroquine base.", + "300 mg chloroquine base is the standard, maximal safe dose that is FDA-approved for adults.", + "The tumor decreased by more than 25% after BRAF MEKi was started.", + "The tumor increased after a drug holiday.", + "The tumor continued to grow despite re-starting therapy with BRAF MEKi.", + "At that point, the autophagy inhibitor chloroquine was added.", + "The addition of chloroquine halted the rate of tumor progression.", + "The addition of chloroquine caused a slight decrease in the lesion size.", + "There are no reported potential interactions between chloroquine and Dabrafenib and/or Trametinib.", + "Chloroquine’s adverse effects can be multisystemic.", + "Chloroquine can cause retinopathy and visual disturbances.", + "Chloroquine can cause prolonged QT interval.", + "Chloroquine can cause pancytopenia.", + "Chloroquine can cause seizures and extrapyramidal signs.", + "We had taken precautionary measures with close monitoring every 1–2 months since started triple therapy.", + "We checked complete blood cells counts, complete metabolic panels, electrocardiogram, and echocardiograms.", + "The patient tolerated the triple therapy well for 17 months.", + "Recently, he complained of mild nausea, diarrhea, and a skin rash.", + "The decision was made to hold chloroquine, while continuing Dabrafenib and Trametinib.", + "Plans were made to re-assess him in 2 months.", + "Radiographically, he has had Stable Disease with BRAF MEKi for 14 months.", + "Radiographically, he has had Stable Disease with the addition of chloroquine for a total of > 2.5 years of treatment.", + "Triple therapy lasted 17 months.", + "There were no major side effects from the treatment until recently.", + "He is receiving a drug holiday from chloroquine." + ], + "summary": "A 20-year-old man found to have a large brain mass with midline shift underwent resection. He was diagnosed with \"GBM\" and treated with radiation and temozolomide with subsequent disease recurrence. Review of histology showed malignant PXA with BRAF V600E mutation. Treatment with Dabrafenib and Trametinib was started, and tumor size increased in size after 14 months of treatment. Given studies showing that resistance to BRAF inhibition can be overcome by autophagy inhibition, chloroquine was added. Patient has been on \"triple\" therapy for 15 months and has radiographically Stable Disease. At MCC, 3% of patients with gliomas have BRAF mutations who could potentially benefit from this combination therapy.", + "summary_subclaims": [ + "A 20-year-old man found to have a large brain mass with midline shift underwent resection.", + "He was diagnosed with \"GBM\".", + "He was treated with radiation and temozolomide.", + "Review of histology showed malignant PXA with BRAF V600E mutation.", + "Treatment with Dabrafenib and Trametinib was started.", + "Tumor size increased in size after 14 months of treatment.", + "Chloroquine was added.", + "Patient has been on \"triple\" therapy for 15 months.", + "Patient has radiographically Stable Disease.", + "At MCC, 3% of patients with gliomas have BRAF mutations who could potentially benefit from this combination therapy." + ] + }, + { + "id": "multiclinsum_test_2588_en.txt", + "fulltext": "A 59-year-old morbidly obese, African-American female had a history of Stage IIIc recurrent endometrial carcinosarcoma with para-aortic and pelvic lymph node involvement. Over several years, after initial surgery, she required repeated bouts of chemotherapy and radiation therapy. She now, however, newly presented with a 1-month history of numbness of the left vulva, worsening left lower extremity pain/numbness, and episodic urinary incontinence. The thoracic/lumbar MR revealed a 1.4 × 1.8 cm enhancing intradural extramedullary mass inferior to the conus at the L1 and L4-L5 levels. In addition, there was abnormal enhancement of the left-sided intradural nerve roots, and the bilateral, perihilar lung metastases .\nThe patient underwent a T12-L2 laminectomy for gross total resection of the L1 intradural/extramedullary mass; the main aim of surgery was to provide neurological symptomatic relief. Intraoperatively, diffuse carcinomatosis of the cauda equina was observed along with a large lesion located anteroinferior to the conus. Grossly, the tumor appeared vascular and involved multiple, swollen, engorged nerve roots. Dissection ceased (e.g., subtotal resection) once intraoperative electromyographic monitoring showed significant changes while dissecting tumor away from tumor infiltrated, matted nerve roots (e.g., gastrocnemius in particular). The permanent pathology showed a mesenchymal malignant Mullerian mixed tumor (carcinosarcoma) without an epithelial component.\nAlthough the postoperative MR revealed residual intradural extramedullary tumor, the pain and numbness improved in her left lower extremity . Nevertheless, she returned to the hospital 2 weeks later complaining of increased lower extremity symptoms and the new onset of right-sided facial weakness, numbness, and blurry vision. Imaging of the brain and spinal cord revealed leptomeningeal spread of her disease accompanied by hydrocephalus and multiple, new intracranial metastases. Two months later, she succumbed to her metastatic disease.", + "fulltext_subclaims": [ + "The patient was a 59-year-old morbidly obese, African-American female.", + "She had a history of Stage IIIc recurrent endometrial carcinosarcoma with para-aortic and pelvic lymph node involvement.", + "She had a 1-month history of numbness of the left vulva.", + "She had worsening left lower extremity pain/numbness.", + "She had episodic urinary incontinence.", + "The thoracic/lumbar MR revealed a 1.4 × 1.8 cm enhancing intradural extramedullary mass inferior to the conus at the L1 and L4-L5 levels.", + "There was abnormal enhancement of the left-sided intradural nerve roots.", + "There were bilateral, perihilar lung metastases.", + "The patient underwent a T12-L2 laminectomy for gross total resection of the L1 intradural/extramedullary mass.", + "The main aim of surgery was to provide neurological symptomatic relief.", + "Intraoperatively, diffuse carcinomatosis of the cauda equina was observed.", + "A large lesion was located anteroinferior to the conus.", + "The tumor appeared vascular and involved multiple, swollen, engorged nerve roots.", + "Dissection ceased once intraoperative electromyographic monitoring showed significant changes.", + "The permanent pathology showed a mesenchymal malignant Mullerian mixed tumor (carcinosarcoma) without an epithelial component.", + "The postoperative MR revealed residual intradural extramedullary tumor.", + "The pain and numbness improved in her left lower extremity.", + "She returned to the hospital 2 weeks later complaining of increased lower extremity symptoms.", + "She had the new onset of right-sided facial weakness, numbness, and blurry vision.", + "Imaging of the brain and spinal cord revealed leptomeningeal spread of her disease.", + "Imaging revealed hydrocephalus.", + "Imaging revealed multiple, new intracranial metastases.", + "Two months later, she succumbed to her metastatic disease." + ], + "summary": "A 59-year-old female with a history of recurrent UCS presented with the new onset of the left lower extremity pain, numbness, and episodic urinary incontinence. When the MR revealed an enhancing intradural extramedullary mass posterior to the L1 vertebral body, she underwent a focal decompressive laminectomy. Although she improved neurologically postoperatively, she succumbed to the leptomeningeal spread of her disease within 2 postoperative months.", + "summary_subclaims": [ + "The patient is a 59-year-old female.", + "The patient has a history of recurrent UCS.", + "The patient had new onset of left lower extremity pain.", + "The patient had new onset of numbness.", + "The patient had episodic urinary incontinence.", + "MR revealed an enhancing intradural extramedullary mass posterior to the L1 vertebral body.", + "The patient underwent a focal decompressive laminectomy.", + "The patient improved neurologically postoperatively.", + "The patient succumbed to the leptomeningeal spread of her disease.", + "The patient died within 2 postoperative months." + ] + }, + { + "id": "multiclinsum_test_540_en.txt", + "fulltext": "On December 11, 2020, a 81-year-old woman presented to the eye hospital of Lucerne, Switzerland, with severe bilateral loss of vision. Eight days earlier, she had received uneventful bilateral injection of brolucizumab, a novel anti-vascular endothelial growth factor (VEGF) single-chain variable region (scFv) recombinant protein drug, for treatment of neovascular age-related macular degeneration (nAMD). The patient had a 2-year history of bilateral nAMD, which had been treated with ten anti-VEGF injections (3 × bevacizumab, 7 × aflibercept) in her right eye, and 12 aflibercept injections in her left eye, with a final treatment interval of every 8 weeks. Her visual acuity was 20/200 in her right eye and 20/400 in her left eye. She had undergone a vitrectomy with membrane peeling for macular pucker, combined with cataract surgery, in the left eye in March 2016. Her relevant medical history included arterial hypertension, osteoporosis, and follicular thyroid carcinoma treated with radiotherapy years ago without metastasis. Current medications included aspirin cardio, euthyrox, lercanidipine, nebivolol, irbesartan, and ibandronate.\nIn September 2020, her treating ophthalmologist switched her anti-VEGF treatment to brolucizumab with the aim of reducing her clinical visits to once every 12 weeks, based on the published data of the HAWK and HARRIER trials . Two weeks after her first same-day bilateral brolucizumab injections, the patient complained of a dark spot in her right peripheral visual field, which remained unchanged until her appointment 8 weeks later, at which she received her second same-day bilateral intravitreal brolucizumab injections. No additional examinations were performed to exclude signs of ocular vasculitis prior to the injections. A follow-up visit the next day revealed a mild anterior chamber reaction on the right eye, and no signs of inflammation on the left. No treatment was deemed necessary. Seven days later, the patient complained of moderate pain, redness, and blurry vision in both eyes. The following day, she presented to our emergency service due to severe vision loss in both eyes.\nAt presentation, her visual acuity in each eye was classified as “hand motions”. Slit-lamp examination revealed marked conjunctivitis with diffuse hemorrhages in both eyes. The cornea of each eye exhibited Descemet folds and severe stromal edema. In both eyes, the anterior chamber was filled with fibrin and dispersed blood on the corneal endothelium, but without a hypopyon , and the iris presented with scattered small hemorrhages. The intraocular pressure was 15 mmHg in her right eye and 8 mmHg in her left eye. The fundus of the right eye was not visible due to cataract and corneal edema, and her left eye exhibited diffuse opacities in the vitreous cavity and dense retinal hemorrhages. Scanning laser ophthalmoscopy of her left eye revealed marked vascular sheathing .\nBased on the lack of hypopyon and an A- and B-scan sonography without hyperreflectivity in the vitreous cavity, infectious endophthalmitis was considered unlikely, and was later excluded since taps from the anterior chamber and vitreous cavity remained negative for eubacterial PCR and microbial culture assay. As the clinical picture resembled an ocular ischemic inflammatory syndrome, temporal arteritis and other forms of vasculitis were considered, but were deemed unlikely due to the patient’s history, lack of painful temporal arteries, and atypical laboratory results.\nWith a working diagnosis of brolucizumab-related vasculitis, immediate treatment was initiated with intravenous methylprednisolone (250 mg) per clinicians discretion, followed by oral prednisolone (1 mg/kilogram body weight). We decided against a complete pulse therapy cycle with IV methylprednisolone after a reviewing the literature that did not show any proven clinical benefit . On the second day of treatment (10 days after second brolucizumab injection), her visual acuity had deteriorated to no light perception in both eyes and remained unchanged thereafter.\nMRI evaluations were performed to search for vasculitis outside the eyeball. T1 fat-saturated post-contrast images of the orbit revealed a higher-than-normal signal of the choroid, with localized choroidal detachment . Additionally, pathologic enhancement was visible around the optic nerve in the orbit, which was interpreted as vasculitis . Black blood MR sequences were also performed, which did not reveal CNS vessel involvement. Due to the suspected severe periocular vaculitis, an additional vitreous tap was obtained, which revealed elevated levels of interleukin 6 (> 300 pg/ml; normal vitreous value in control group: < 30 pg/ml) and interleukin 10 (40.6 pg/ml; normal vitreous value: < 3 pg/ml) . Conjunctival biopsy of the left eye showed edema and inflammation, with intracapillary granulocyte accumulation. In the following days, intraocular pressure dropped to 1 mmHg in her right eye and 6 mmHg in her left eye, with signs of a bilateral panocular ischemia.", + "fulltext_subclaims": [ + "The patient was an 81-year-old woman.", + "She presented to the eye hospital of Lucerne, Switzerland, on December 11, 2020.", + "She had severe bilateral loss of vision.", + "Eight days earlier, she had received uneventful bilateral injection of brolucizumab.", + "Brolucizumab is a novel anti-vascular endothelial growth factor (VEGF) single-chain variable region (scFv) recombinant protein drug.", + "She had a 2-year history of bilateral neovascular age-related macular degeneration (nAMD).", + "She had been treated with ten anti-VEGF injections in her right eye.", + "She had been treated with 12 aflibercept injections in her left eye.", + "Her final treatment interval was every 8 weeks.", + "Her visual acuity was 20/200 in her right eye.", + "Her visual acuity was 20/400 in her left eye.", + "She had undergone a vitrectomy with membrane peeling for macular pucker in the left eye in March 2016.", + "She had a history of follicular thyroid carcinoma treated with radiotherapy years ago without metastasis.", + "She was taking aspirin cardio, euthyrox, lercanidipine, nebivolol, irbesartan, and ibandronate.", + "Her treating ophthalmologist switched her anti-VEGF treatment to brolucizumab in September 2020.", + "The switch was based on the published data of the HAWK and HARRIER trials.", + "The aim of the switch was to reduce her clinical visits to once every 12 weeks.", + "Two weeks after her first same-day bilateral brolucizumab injections, she complained of a dark spot in her right peripheral visual field.", + "The dark spot remained unchanged until her appointment 8 weeks later.", + "At that appointment, she received her second same-day bilateral intravitreal brolucizumab injections.", + "No additional examinations were performed to exclude signs of ocular vasculitis prior to the injections.", + "A follow-up visit the next day revealed a mild anterior chamber reaction on the right eye.", + "No signs of inflammation were found on the left eye.", + "No treatment was deemed necessary.", + "Seven days later, the patient complained of moderate pain, redness, and blurry vision in both eyes.", + "The following day, she presented to the emergency service due to severe vision loss in both eyes.", + "At presentation, her visual acuity in each eye was classified as 'hand motions'.", + "Slit-lamp examination revealed marked conjunctivitis with diffuse hemorrhages in both eyes.", + "The cornea of each eye exhibited Descemet folds and severe stromal edema.", + "The anterior chamber was filled with fibrin and dispersed blood on the corneal endothelium in both eyes.", + "The anterior chamber showed no hypopyon.", + "The iris presented with scattered small hemorrhages.", + "The intraocular pressure was 15 mmHg in her right eye.", + "The intraocular pressure was 8 mmHg in her left eye.", + "The fundus of the right eye was not visible due to cataract and corneal edema.", + "Her left eye exhibited diffuse opacities in the vitreous cavity and dense retinal hemorrhages.", + "Scanning laser ophthalmoscopy of her left eye revealed marked vascular sheathing.", + "Infectious endophthalmitis was considered unlikely.", + "Taps from the anterior chamber and vitreous cavity remained negative for eubacterial PCR and microbial culture assay.", + "The clinical picture resembled an ocular ischemic inflammatory syndrome.", + "Temporal arteritis and other forms of vasculitis were considered.", + "Temporal arteritis and other forms of vasculitis were deemed unlikely due to the patient’s history, lack of painful temporal arteries, and atypical laboratory results.", + "With a working diagnosis of brolucizumab-related vasculitis, treatment was initiated with intravenous methylprednisolone (250 mg) per clinicians discretion.", + "Treatment was followed by oral prednisolone (1 mg/kilogram body weight).", + "A complete pulse therapy cycle with IV methylprednisolone was decided against.", + "The literature did not show any proven clinical benefit for a complete pulse therapy cycle.", + "On the second day of treatment, her visual acuity had deteriorated to no light perception in both eyes.", + "Her visual acuity remained unchanged thereafter.", + "MRI evaluations were performed to search for vasculitis outside the eyeball.", + "T1 fat-saturated post-contrast images of the orbit revealed a higher-than-normal signal of the choroid.", + "Localized choroidal detachment was noted.", + "Pathologic enhancement was visible around the optic nerve in the orbit.", + "The enhancement was interpreted as vasculitis.", + "Black blood MR sequences did not reveal CNS vessel involvement.", + "An additional vitreous tap was obtained due to suspected severe periocular vasculitis.", + "The vitreous tap revealed elevated levels of interleukin 6 (> 300 pg/ml; normal vitreous value in control group: < 30 pg/ml).", + "The vitreous tap revealed elevated levels of interleukin 10 (40.6 pg/ml; normal vitreous value: < 3 pg/ml).", + "Conjunctival biopsy of the left eye showed edema and inflammation.", + "Intracapillary granulocyte accumulation was noted in the conjunctival biopsy.", + "In the following days, intraocular pressure dropped to 1 mmHg in her right eye.", + "In the following days, intraocular pressure dropped to 6 mmHg in her left eye.", + "Signs of bilateral panocular ischemia were noted." + ], + "summary": "On December 11, 2020, a 81-year-old woman presented with severe bilateral loss of vision. Eight days earlier, she had received uneventful bilateral injection of brolucizumab, a novel anti-vascular endothelial growth factor (VEGF) single-chain variable region (scFv) recombinant protein drug, for treatment of neovascular age-related macular degeneration (nAMD). Slit-lamp examination revealed signs of a bilateral panocular vasculitis with ischemia. Scanning laser ophthalmoscopy of her left eye revealed marked vascular sheathing. T1 fat-saturated post-contrast images of the orbit revealed a higher-than-normal signal of the choroid, with localized choroidal detachment. Additionally, pathologic enhancement was visible around the optic nerve in the orbit, which was interpreted as vasculitis. Due to the severe bilateral panuveitis with vasculitis, an additional vitreous tap was obtained, which revealed elevated levels of interleukin six and interleukin ten.", + "summary_subclaims": [ + "The patient was an 81-year-old woman.", + "She presented on December 11, 2020.", + "She had severe bilateral loss of vision.", + "Eight days earlier, she had received uneventful bilateral injection of brolucizumab.", + "Brolucizumab is a novel anti-vascular endothelial growth factor (VEGF) single-chain variable region (scFv) recombinant protein drug.", + "The drug was used for treatment of neovascular age-related macular degeneration.", + "Slit-lamp examination revealed signs of a bilateral panocular vasculitis with ischemia.", + "Scanning laser ophthalmoscopy of her left eye revealed marked vascular sheathing.", + "T1 fat-saturated post-contrast images of the orbit revealed a higher-than-normal signal of the choroid.", + "Localized choroidal detachment was noted.", + "Pathologic enhancement was visible around the optic nerve in the orbit.", + "The pathologic enhancement was interpreted as vasculitis.", + "An additional vitreous tap was obtained.", + "Elevated levels of interleukin six were found.", + "Elevated levels of interleukin ten were found." + ] + }, + { + "id": "multiclinsum_test_2174_en.txt", + "fulltext": "A 22-year-old female arrived at the Emergency Department presenting claudication when walking less than 300 m as well as increased paresthesia and dysesthesia in both pelvic limbs. The claudication, paresthesia, and dysesthesia began five years earlier. At the time of onset, the claudication was bilateral after walking approximately 1500 m with improvement after rest, while the paresthesia and dysesthesia were bilateral and involved all four extremities. At that time, the patient was diagnosed with Takayasu’s arteritis (TA) by the Rheumatology department from this institution based on immunological profile (i.e. rheumatoid factor, antinuclear antibodies, anticardiolipin antibodies, and antineutrophil cytoplasmic antibodies (ANCA), the American College of Rheumatology and Ishikawa criteria. [,] Six months prior to the patient’s visit to this hospital, claudication progressed (i.e. reduction in the distance able to walk to 500 m, increasing paresthesia and dysesthesia frequency). The patient had no relevant family and personal non-pathological history to her current condition. The patient denied the use of controlled substances, allergies, past blood transfusions, traveling to regions with endemic diseases within the last three months, tattoos and body piercings.\nUpon initial physical examination, we found a patient recumbent with freely chosen body position, Glasgow coma score of 15, without focal neurologic deficits nor meningeal sings, aware of his environment, with reference to place, time, and people. The patient’s integumentary system was hydrated and without alterations, while the head and neck exploration had no alterations. Upon inspection, palpation, and percussion the cardio-respiratory system and abdomen had no abnormal findings. Precordial auscultation revealed tachycardia, but no aggregate phenomena. Abdominal auscultation revealed a systolic murmur grade III/IV at the mesogastrium. Right upper limb exploration revealed normal axillar, humeral, and radial pulses (i.e. presence of rhythmic, with normal intensity +++/+++, normal amplitude, and having a synchronous frequency with heart rate). The right ulnar artery pulse was absent. Upon left upper limb exploration, palpation showed the presence of normal axillar and humeral pulses; while radial and ulnar pulses were absent. Lower limb exploration showed absence of bilateral femoral, popliteal and posterior tibial pulses. The skin presented cyanotic appearance, especially of the toes of both feet. Upon palpation, reduced skin temperature was noticed and absence of edema. Upon admission, the patient had the following vital signs: blood pressure 100/70 mmHg in the right arm, 80/60 mmHg in the left arm, blood pressure in the right leg and the left leg were not detectable; heart rate 85bpm; respiratory rate 17 rpm; temperature 36 °C; weight 65 kg; height 167 cm; body mass index23.3 kg/m . Laboratory results at admission are presented in and the follow-up laboratory results in .", + "fulltext_subclaims": [ + "The patient is a 22-year-old female.", + "She presented with claudication when walking less than 300 m.", + "She had increased paresthesia and dysesthesia in both pelvic limbs.", + "The claudication, paresthesia, and dysesthesia began five years earlier.", + "At the time of onset, the claudication was bilateral after walking approximately 1500 m.", + "At the time of onset, the claudication improved after rest.", + "At the time of onset, the paresthesia and dysesthesia were bilateral.", + "At the time of onset, the paresthesia and dysesthesia involved all four extremities.", + "The patient was diagnosed with Takayasu’s arteritis by the Rheumatology department.", + "The diagnosis was based on immunological profile.", + "The diagnosis was based on the American College of Rheumatology and Ishikawa criteria.", + "Six months prior to the visit, claudication progressed.", + "Six months prior to the visit, the distance able to walk was reduced to 500 m.", + "Six months prior to the visit, paresthesia and dysesthesia frequency increased.", + "The patient had no relevant family history.", + "The patient had no relevant personal non-pathological history.", + "The patient denied the use of controlled substances.", + "The patient denied allergies.", + "The patient denied past blood transfusions.", + "The patient denied traveling to regions with endemic diseases within the last three months.", + "The patient denied tattoos and body piercings.", + "Upon initial physical examination, the patient was recumbent with freely chosen body position.", + "The Glasgow coma score was 15.", + "There were no focal neurologic deficits.", + "There were no meningeal signs.", + "The integumentary system was hydrated and without alterations.", + "The head and neck exploration had no alterations.", + "The cardio-respiratory system had no abnormal findings.", + "The abdomen had no abnormal findings.", + "Precordial auscultation revealed tachycardia.", + "Abdominal auscultation revealed a systolic murmur grade III/IV at the mesogastrium.", + "Right upper limb exploration revealed normal axillar, humeral, and radial pulses.", + "The right ulnar artery pulse was absent.", + "Left upper limb exploration showed normal axillar and humeral pulses.", + "Left radial and ulnar pulses were absent.", + "Lower limb exploration showed absence of bilateral femoral, popliteal, and posterior tibial pulses.", + "The skin presented cyanotic appearance, especially of the toes of both feet.", + "Upon palpation, reduced skin temperature was noticed.", + "There was absence of edema.", + "Upon admission, blood pressure was 100/70 mmHg in the right arm.", + "Upon admission, blood pressure was 80/60 mmHg in the left arm.", + "Upon admission, blood pressure in the right leg was not detectable.", + "Upon admission, blood pressure in the left leg was not detectable.", + "Upon admission, heart rate was 85bpm.", + "Upon admission, respiratory rate was 17 rpm.", + "Upon admission, temperature was 36 °C.", + "Upon admission, weight was 65 kg.", + "Upon admission, height was 167 cm.", + "Upon admission, body mass index was 23.3 kg/m." + ], + "summary": "The case of a 22-year-old female with TA of five years of evolution is presented. The patient deteriorated clinically after five years of corticosteroid and immunosuppressant management requiring surgical intervention with an axillobifemoral bypass for a total abdominal occlusion. Onset, pre-surgical and post-surgical Doppler ultrasonography as well as abdominal angiotomographies document and corroborate the patient's clinical and hemodynamic improvement.", + "summary_subclaims": [ + "The patient is a 22-year-old female.", + "The patient has TA of five years of evolution.", + "The patient deteriorated clinically after five years of corticosteroid and immunosuppressant management.", + "The patient required surgical intervention with an axillobifemoral bypass.", + "The surgical intervention was for a total abdominal occlusion.", + "Onset, pre-surgical and post-surgical Doppler ultrasonography document the patient's clinical and hemodynamic improvement.", + "Abdominal angiotomographies document and corroborate the patient's clinical and hemodynamic improvement." + ] + }, + { + "id": "multiclinsum_test_3097_en.txt", + "fulltext": "A 10-year-old male child presented to our surgery clinic on October 2021 with a chief complaint of abdominal pain and vomiting for the past ten months. The pain was frequent, colicky, postprandial, and generalized. It was aggravated by eating and associated with vomiting, anorexia, and weight loss. There was no history of hematuria, rectal bleeding, or diarrhea. There is a history of chronic constipation and environmental exposures to unclean water. The patient lived in a village and owned a dog and cheeps, which he kept in the house. In addition, he has a family history of lymphoma in his brother.\n\nOn physical examination, the patient looked ill with no pallor or jaundice. There was a nonmobile, non-tender, palpable right iliac fossa mass on abdominal examination.\n\nThe laboratory data were as follows: total white blood cell count: 12 ×103/mL, hemoglobin:14.4 g/dl, blood urea nitrogen: 35 mg/dl, creatinine: 0.9 mg/dl, serum albumin: 4.2 g/dL, serum bilirubin: 1 mg/dL, and negative for viral hepatitis. The urinalysis and stool examination were normal.\n\nUltrasonography (US) of the abdomen showed a segmental wall thickening of the ascending colon and 10×3 cm intraluminal sigmoid mass suggestive of an intestinal tumor or lymphoma. The computed tomography (CT) scan of the chest and abdomen showed that the sigmoid is redundant and seen on the right lower abdominal quadrant before its cross midline and joins the descending colon, diffuse circumferential wall thickening of the sigmoid colon, and 10×3 cm intraluminal mass with significant lumen narrowing. There were multiple perilesional lymph nodes; the largest one was measuring 1.4x1cm. There was hepatomegaly with heterogenous contrast enhancement without a definite lesion. In addition, there were multiple para-hepatic, and pulmonary lymph nodes enlargements. Based on the CT findings (extranodal lymph nodes enlargements and multiple general lymphadenopathies) and the family history of malignancy, the possibility of malignancy could not be excluded. After a multidisciplinary discussion, the decision was made for an open surgical exploration.\n\nAfter general anesthesia and lower midline incision, the abdominal cavity was opened, revealing a sigmoid colon attached to the abdominal wall at the right lower quadrant, a large sigmoid mass measuring about 15 cm, and multiple mesenteric and paraaortic lymph nodes enlargements. Sigmoidectomy with a safety margins and primary anastomosis were performed, and the specimen was sent for pathologic assessment.\n\n\nFollow-Up and Outcome\nThe postoperative period was uneventful, and he was tolerating a regular diet. The patient was discharged home on the fifth postoperative day. The histopathology reported that numerous non-caseating granulomas formed of bilharzial ova (Schistosoma mansoni) and multinucleated giant cells. The patient was referred to the pediatric infectious disease clinic and was treated with three doses of praziquantel (60 mg/kg). Within five months of follow-up, the patient remained symptom-free.", + "fulltext_subclaims": [ + "The patient is a 10-year-old male child.", + "The patient presented to the surgery clinic on October 2021.", + "The chief complaint was abdominal pain and vomiting for the past ten months.", + "The pain was frequent, colicky, postprandial, and generalized.", + "The pain was aggravated by eating.", + "The pain was associated with vomiting.", + "There was a history of chronic constipation.", + "The patient lived in a village.", + "The patient owned a dog and cheeps, which he kept in the house.", + "There was a family history of lymphoma in his brother.", + "On physical examination, there was a nonmobile, non-tender, palpable right iliac fossa mass.", + "The total white blood cell count was 12 ×103/mL.", + "The blood urea nitrogen was 35 mg/dl.", + "The urinalysis was normal.", + "The stool examination was normal.", + "Ultrasonography showed a segmental wall thickening of the ascending colon.", + "Ultrasonography showed a 10×3 cm intraluminal sigmoid mass suggestive of an intestinal tumor or lymphoma.", + "The CT scan showed diffuse circumferential wall thickening of the sigmoid colon.", + "The CT scan showed a 10×3 cm intraluminal mass with significant lumen narrowing.", + "The CT scan showed multiple perilesional lymph nodes.", + "The largest lymph node measured 1.4x1cm.", + "The CT scan showed hepatomegaly with heterogenous contrast enhancement.", + "The CT scan showed multiple para-hepatic lymph node enlargements.", + "The CT scan showed multiple pulmonary lymph node enlargements.", + "Based on the CT findings and family history of malignancy, the possibility of malignancy could not be excluded.", + "The decision was made for an open surgical exploration.", + "After general anesthesia and lower midline incision, the abdominal cavity was opened.", + "A large sigmoid mass measuring about 15 cm was found.", + "Multiple mesenteric and paraaortic lymph nodes enlargements were found.", + "Sigmoidectomy with safety margins and primary anastomosis were performed.", + "The postoperative period was uneventful.", + "The patient was discharged home on the fifth postoperative day.", + "The histopathology reported numerous non-caseating granulomas formed of bilharzial ova (Schistosoma mansoni).", + "The histopathology reported multinucleated giant cells.", + "The patient was treated with three doses of praziquantel (60 mg/kg).", + "Within five months of follow-up, the patient remained symptom-free." + ], + "summary": "A 10-year-old child presented with chronic abdominal pain that started ten months ago. The patient had a family history of lymphoma in his brother. The computed tomography scan showed a sigmoid luminal mass measuring 10×3 cm with significant lumen narrowing and diffuse circumferential wall thickening of the sigmoid colon, hepatomegaly, and multiple perilesional, para-hepatic, and pulmonary lymph nodes enlargements. The mass was morphologically mimicked cancer and proved to be of bilharzial etiology (Schistosoma mansoni) after surgical excision.", + "summary_subclaims": [ + "The patient is a 10-year-old child.", + "The patient presented with chronic abdominal pain.", + "The chronic abdominal pain started ten months ago.", + "The patient had a family history of lymphoma in his brother.", + "The computed tomography scan showed a sigmoid luminal mass measuring 10×3 cm.", + "The computed tomography scan showed significant lumen narrowing.", + "The computed tomography scan showed diffuse circumferential wall thickening of the sigmoid colon.", + "The computed tomography scan showed hepatomegaly.", + "The computed tomography scan showed multiple perilesional lymph nodes enlargements.", + "The computed tomography scan showed multiple para-hepatic lymph nodes enlargements.", + "The computed tomography scan showed multiple pulmonary lymph nodes enlargements.", + "The mass was morphologically mimicked cancer.", + "The mass proved to be of bilharzial etiology after surgical excision.", + "The mass was of Schistosoma mansoni etiology." + ] + }, + { + "id": "multiclinsum_test_3328_en.txt", + "fulltext": "A 36-year-old man with a history of HOCM presented with exertional dyspnoea and recurrent syncope. Despite 6 years of beta-blocker therapy (metoprolol succinate 47.5 mg once daily), his symptoms remained unresolved. Over the past 6 months, he experienced more than 10 syncopal episodes. These brief episodes, lasting only a few seconds, were typically triggered by positional changes, physical activity, or heavy meals, though they were rarely observed while sitting. On cardiovascular examination, a prominent systolic murmur was audible along the left sternal border.\n\nEchocardiography revealed a thickened interventricular septum (IVS) (25 mm), elongation of the anterior and posterior mitral leaflets, SAM of the mitral leaflet, and moderate posterior mitral regurgitation. The LVOT gradient was 85 mmHg at rest, rising to 103 mmHg during a semi-recumbent bicycle exercise stress test. No arrhythmias or abnormal blood pressure responses were observed during exercise. Holter monitoring showed no evidence of non-sustained ventricular tachycardias (VTs) or significant heart block. Electrocardiogram (ECG): Before the procedure, the ECG showed normal sinus rhythm with ST-segment depression in leads I, II, III, aVF, and V4–V6. During the patient’s shock period, the ECG revealed a significant ST-segment depressed, with a maximum of 0.7 mV in lead II. STv1,2 elevated 0.3 mv. Cardiac magnetic resonance imaging confirmed interventricular septal hypertrophy (maximal LV wall thickness of 24.6 mm and LV mass of 216.4 g), with patchy late gadolinium enhancement (6.98% of total LV mass). The patient’s HCM Risk-SCD score was 9.66%. An implantable cardioverter-defibrillator was recommended for primary prevention of sudden cardiac death, but the patient declined.\n\nAfter a multidisciplinary discussion, PIMSRA was selected as the treatment option. The patient was placed in the left lateral position following general anaesthesia and endotracheal intubation. Under real-time guidance from transthoracic echocardiography (TTE), the radiofrequency electrode needle (ACT1520) was inserted percutaneously through the myocardium into the hypertrophied IVS. The radiofrequency energy was initiated at 40 W and gradually increased to 70 W. The entire procedure lasted 46 min, with six ablations performed at the most hypertrophic regions of the septum. After the procedure, the diameter of the IVS remained at the pre-PIMSRA level of 25 mm, but the LVOT gradient from 85 mmHg reduced to 25 mmHg, with a notable reduction in mitral regurgitation.\n\nOne hour after the procedure, the patient’s blood pressure dropped sharply to 60/40 mmHg, accompanied by a significant increase in heart rate to 90 b.p.m. Electrocardiogram monitoring did not show malignant arrhythmias. Emergency TTE revealed that the anterior mitral leaflet (AML) had abnormally displaced proximally, moving close to the septum, and was associated with severe mitral regurgitation. The left atrium significantly enlarged to 49.2 mm, while the septum diameter remained unchanged at 25 mm. The patient lost consciousness quickly. He received emergency rapid fluid resuscitation and a high-dose intravenous norepinephrine infusion to stabilize his blood pressure. After 10 min, the patient regained consciousness, and his blood pressure stabilized at 130/70 mmHg. The TTE showed resolution of SAM and mitral regurgitation.\n\nAt the 3-month follow-up, the patient had no further episodes of syncope. Echocardiography revealed an interventricular septum measuring 18 mm (compared to 25 mm before the procedure) and an LVOT gradient of 10 mmHg at rest, increasing to 16 mmHg with the Valsalva manoeuvre. Additionally, SAM was no longer present, and there was no mitral regurgitation. Holter ECG conducted 3 months after the procedure showed no evidence of non-sustained VT. Eighteen months after the procedure, the patient remained symptom-free, with no recurrence of syncope, indicating a favourable outcome following PIMSRA.", + "fulltext_subclaims": [ + "The patient is a 36-year-old man.", + "He has a history of HOCM.", + "He presented with exertional dyspnoea.", + "He had recurrent syncope.", + "He had been on beta-blocker therapy (metoprolol succinate 47.5 mg once daily) for 6 years.", + "His symptoms remained unresolved.", + "He experienced more than 10 syncopal episodes over the past 6 months.", + "The syncopal episodes lasted only a few seconds.", + "The episodes were typically triggered by positional changes.", + "The episodes were typically triggered by physical activity.", + "The episodes were typically triggered by heavy meals.", + "The episodes were rarely observed while sitting.", + "A prominent systolic murmur was audible along the left sternal border.", + "Echocardiography revealed a thickened interventricular septum (IVS) of 25 mm.", + "Echocardiography showed elongation of the anterior and posterior mitral leaflets.", + "Echocardiography showed SAM of the mitral leaflet.", + "Echocardiography showed moderate posterior mitral regurgitation.", + "The LVOT gradient was 85 mmHg at rest.", + "The LVOT gradient increased to 103 mmHg during a semi-recumbent bicycle exercise stress test.", + "No arrhythmias were observed during exercise.", + "No abnormal blood pressure responses were observed during exercise.", + "Holter monitoring showed no evidence of non-sustained ventricular tachycardias.", + "The ECG before the procedure showed normal sinus rhythm.", + "The ECG before the procedure showed ST-segment depression in leads I, II, III, aVF, and V4–V6.", + "The HCM Risk-SCD score was 9.66%.", + "An implantable cardioverter-defibrillator was recommended for primary prevention of sudden cardiac death.", + "The patient declined the implantable cardioverter-defibrillator.", + "PIMSRA was selected as the treatment option.", + "The patient was placed in the left lateral position.", + "The radiofrequency electrode needle (ACT1520) was inserted percutaneously through the myocardium into the hypertrophied IVS.", + "The radiofrequency energy was initiated at 40 W.", + "The radiofrequency energy was increased to 70 W.", + "The entire procedure lasted 46 min.", + "Six ablations were performed at the most hypertrophic regions of the septum.", + "After the procedure, the diameter of the IVS remained at 25 mm.", + "The LVOT gradient reduced from 85 mmHg to 25 mmHg.", + "There was a notable reduction in mitral regurgitation.", + "One hour after the procedure, the patient’s blood pressure dropped to 60/40 mmHg.", + "The patient’s heart rate increased to 90 b.p.m.", + "Emergency TTE revealed that the anterior mitral leaflet had abnormally displaced proximally.", + "The anterior mitral leaflet moved close to the septum.", + "Severe mitral regurgitation was associated with the displacement.", + "The left atrium enlarged to 49.2 mm.", + "The patient lost consciousness quickly.", + "He received emergency rapid fluid resuscitation.", + "He received a high-dose intravenous norepinephrine infusion.", + "After 10 min, the patient regained consciousness.", + "The patient’s blood pressure stabilized at 130/70 mmHg.", + "The TTE showed resolution of SAM.", + "The TTE showed resolution of mitral regurgitation.", + "At the 3-month follow-up, the patient had no further episodes of syncope.", + "Echocardiography revealed an interventricular septum measuring 18 mm.", + "The LVOT gradient was 10 mmHg at rest.", + "The LVOT gradient increased to 16 mmHg with the Valsalva manoeuvre.", + "SAM was no longer present.", + "There was no mitral regurgitation.", + "Holter ECG showed no evidence of non-sustained VT.", + "Eighteen months after the procedure, the patient remained symptom-free.", + "There was no recurrence of syncope." + ], + "summary": "A 36-year-old male with HOCM presented with recurrent episodes of syncope. After a multidisciplinary evaluation, he underwent percutaneous intramyocardial septal radiofrequency ablation (PIMSRA). Approximately 1-h post-procedure, the patient developed severe haemodynamic collapse. Transthoracic echocardiography revealed abnormal proximal displacement of the anterior mitral valve leaflet, bringing it into close proximity with the septum. The patient was treated emergently with high-dose intravenous norepinephrine, stabilizing his condition. At the 18-month follow-up, the patient reported no recurrence of syncope.", + "summary_subclaims": [ + "The patient is a 36-year-old male.", + "The patient has HOCM.", + "The patient had recurrent episodes of syncope.", + "The patient underwent percutaneous intramyocardial septal radiofrequency ablation.", + "Approximately 1-h post-procedure, the patient developed severe haemodynamic collapse.", + "Transthoracic echocardiography revealed abnormal proximal displacement of the anterior mitral valve leaflet.", + "The anterior mitral valve leaflet was brought into close proximity with the septum.", + "The patient was treated emergently with high-dose intravenous norepinephrine.", + "The patient's condition stabilized.", + "At the 18-month follow-up, the patient reported no recurrence of syncope." + ] + }, + { + "id": "multiclinsum_test_201_en.txt", + "fulltext": "A 64-year-old female patient presented with blurry, double, and starburst vision in her right eye, accompanied by a one-year history of decreasing visual acuity. Her ocular background involved chronic angle-closure glaucoma. Four years prior, she underwent trabeculectomy surgery along with cataract phacoemulsification and PCIOL implantation in both eyes. Additionally, she has a medical history of osteoarthritis and an inguinal hernia. Two months post-surgery, the anterior capsule of her left eye contracted rapidly, and Nd: YAG capsulotomy therapy was employed to restore visual acuity. Throughout the follow-up, intraocular pressure in both eyes ranged between 18 and 21 mmHg.\nRecently, her right eye’s best-corrected visual acuity (BCVA) had been gradually declining and was now 6/20. Clear corneas, typical anterior chambers devoid of cells or flare, and a properly positioned posterior chamber intraocular lens (PCIOL) were observed during slit lamp inspection. However, the pupil was only slightly dilated at 3.5 mm. Examination revealed collections of the OS in the right eye trapped between the retro-IOL surface and the hyper-distended posterior capsule in the posterior chamber . Utilizing the IOL master (Carl Zeiss Meditec AG, Germany) and ultrasound biomicroscopy (UBM, SW-3200 L, Tianjin), preoperative biometry measured an axial length of 20.66 mm, anterior chamber depth (ACD) of 2.90 mm, and the distance between the PCIOL surface and posterior capsule of 1.96 mm, respectively . No space was observed between the posterior iris surface and the lens-complex interface. According to UBM, a weak echo was reflected following the IOL and posterior capsule, with a dot/cluster echo towards the posterior capsule’s bottom. B-scan ultrasound (Esaote, Genova, Italy) did not reveal any noteworthy abnormalities. Simultaneously, measurements for the left eye indicated a 20/20 BCVA, a 20.31 mm axial length, and a 2.81 mm ACD. Examination of the posterior segments of both eyes revealed nearly normal macular anatomy, with a cup-to-disc ratio of 0.5 in both eyes. Itrace’s visual quality (VQ) analysis indicated that coma and trefoil in the internal eye were the primary causes of blur, double vision, starbursts, and decreased contrast sensitivity. The presence of a trapped OS and a hyper-distended posterior capsule could contribute to confusing low VQ across all indications. All evidence suggested late-onset CBS occurring in her right eye based on the trapped OS and the apparent absence of anterior and/or posterior inflammation. However, Nd: YAG laser capsulotomy therapy was constrained by the small pupil and hyper-distended posterior capsule.\nOnce permission was granted, the patient underwent local anesthesia for pars plana anterior vitrectomy, pupil reformation, posterior capsulotomy, release of opaque material with an inflammatory cytokine test, and other necessary procedures. Iris hooks assisted in visualizing a roughly 3.5 mm-sized white anterior capsule, though shrinking during surgery, which showed signs of fibrosis around its entire perimeter. No retained cortex was observed, and the posterior capsule remained non-turbid. Using a 23-gauge trocar, a 3.5 mm pars plana port cannula was created from the limbus. Initially, attempts to remove OS from the posterior chamber using a 30-gauge needle were hindered by negative pressure, indicating a sealed area between the posterior capsule and the retro-IOL surface. Subsequently, the posterior capsule was penetrated, and the capsular bag contents were aspirated by a cutter through the super-temporal port, with irrigation closed infra-temporally. For the analysis of inflammatory cytokines, the aspirated fluid was promptly transferred and maintained at a temperature of 4 °C. The remaining anterior capsular, enlarged to a diameter of 6 mm, was released after careful peeling off of the fibrosis anterior capsular ring. The ring material was then fixed for pathology study. A 4 mm diameter posterior capsulotomy was performed in the center using a 23-gauge vitrectomy, followed by a local anterior vitrectomy. Pathological examination of the 3 × 2 mm area and 1 mm thick fibrosis anterior capsular material revealed innocent fibrotic cystic tissue with minor pigment accumulation. Cytokine analysis using a flow cytometer multiple array assay device identified changes in some cytokines, including up-regulation of BFGF, IL-8, and down-regulation of VCAM .\nThe patient was monitored for 6 months, with a positive postoperative phase and an improvement in BCVA to 20/25. The anterior chamber’s depth increased slightly from 2.90 to 2.95 mm. This procedure also addressed other CBS issues, such as improved pupil function, release of the trapped OS, proper placement of the IOL in the bag, and the absence of aberrant IOL deposits . The absence of visual complaints confirmed the successful treatment of coma and trefoil in the internal eye through Itrace analysis. Due to a history of glaucoma, fundoscopy and optic coherence tomography revealed moderate optic atrophy.", + "fulltext_subclaims": [ + "A 64-year-old female patient presented with blurry, double, and starburst vision in her right eye.", + "She had a one-year history of decreasing visual acuity.", + "Her ocular background involved chronic angle-closure glaucoma.", + "Four years prior, she underwent trabeculectomy surgery along with cataract phacoemulsification and PCIOL implantation in both eyes.", + "She has a medical history of osteoarthritis.", + "She has a medical history of an inguinal hernia.", + "Two months post-surgery, the anterior capsule of her left eye contracted rapidly.", + "Nd: YAG capsulotomy therapy was employed to restore visual acuity.", + "Intraocular pressure in both eyes ranged between 18 and 21 mmHg.", + "Her right eye’s best-corrected visual acuity (BCVA) was now 6/20.", + "Clear corneas were observed during slit lamp inspection.", + "The pupil was only slightly dilated at 3.5 mm.", + "Examination revealed collections of the OS in the right eye trapped between the retro-IOL surface and the hyper-distended posterior capsule.", + "Preoperative biometry measured an axial length of 20.66 mm.", + "The distance between the PCIOL surface and posterior capsule was 1.96 mm.", + "No space was observed between the posterior iris surface and the lens-complex interface.", + "A weak echo was reflected following the IOL and posterior capsule.", + "B-scan ultrasound did not reveal any noteworthy abnormalities.", + "The left eye had a 20/20 BCVA.", + "The left eye had a 20.31 mm axial length.", + "Examination of the posterior segments of both eyes revealed nearly normal macular anatomy.", + "The cup-to-disc ratio was 0.5 in both eyes.", + "Itrace’s visual quality (VQ) analysis indicated that coma and trefoil in the internal eye were the primary causes of blur, double vision, starbursts, and decreased contrast sensitivity.", + "The presence of a trapped OS and a hyper-distended posterior capsule could contribute to confusing low VQ across all indications.", + "All evidence suggested late-onset CBS occurring in her right eye.", + "Nd: YAG laser capsulotomy therapy was constrained by the small pupil and hyper-distended posterior capsule.", + "The patient underwent local anesthesia for pars plana anterior vitrectomy.", + "Iris hooks assisted in visualizing a roughly 3.5 mm-sized white anterior capsule.", + "The posterior capsule remained non-turbid.", + "A 3.5 mm pars plana port cannula was created from the limbus.", + "Attempts to remove OS from the posterior chamber using a 30-gauge needle were hindered by negative pressure.", + "The posterior capsule was penetrated, and the capsular bag contents were aspirated by a cutter through the super-temporal port.", + "The aspirated fluid was promptly transferred and maintained at a temperature of 4 °C.", + "The remaining anterior capsular, enlarged to a diameter of 6 mm, was released after careful peeling off of the fibrosis anterior capsular ring.", + "A 4 mm diameter posterior capsulotomy was performed in the center using a 23-gauge vitrectomy.", + "Pathological examination of the 3 × 2 mm area and 1 mm thick fibrosis anterior capsular material revealed innocent fibrotic cystic tissue with minor pigment accumulation.", + "Cytokine analysis identified changes in some cytokines, including up-regulation of BFGF, IL-8, and down-regulation of VCAM.", + "The patient was monitored for 6 months.", + "The postoperative phase was positive.", + "BCVA improved to 20/25.", + "The anterior chamber’s depth increased slightly from 2.90 to 2.95 mm.", + "The procedure addressed other CBS issues, such as improved pupil function.", + "The absence of visual complaints confirmed the successful treatment of coma and trefoil in the internal eye.", + "Fundoscopy and optic coherence tomography revealed moderate optic atrophy." + ], + "summary": "A 64-year-old female patient with chronic angle-closure glaucoma (axis length < 21 mm) underwent trabeculectomy surgery combined with phacoemulsification and PCIOL. After a 4-year follow-up, a decline in visual acuity occurred in her right eye due to the location of opaque fluid in the visual axis and distension of the capsular bag. The initial course of action was to release the trapped fluid. Neodymium: yttrium-aluminum-garnet (Nd: YAG) laser capsulotomy could not be employed due to her non-dilating pupil and high extension of the posterior capsule. Subsequently, anterior capsule peeling and anterior segment vitrectomy surgery were performed. The depth of the anterior chamber (ACD), the distance between the face of the retro-IOL and the posterior capsule, the best-corrected visual acuity (BCVA), and the visual quality (VQ) were measured both before and after surgery. Inflammatory cytokine levels in the opaque substances (OS) trapped between the PCIOL and the posterior capsule were assessed using a flow cytometer and compared to normal statistical data in aqueous humor. After surgery, the patient experienced a significant improvement in BCVA and VQ. The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing. However, ACD did not differ between pre- and post-operatively. Interleukin-8 (IL-8) and basic fibroblast growth factor (BFGF) concentrations were higher in the OS than in aqueous humor, especially in the former. However, the concentration of vascular cell adhesion molecule (VCAM) in the OS was lower than in aqueous humor.", + "summary_subclaims": [ + "The patient is a 64-year-old female.", + "The patient has chronic angle-closure glaucoma.", + "The patient's axis length is less than 21 mm.", + "The patient underwent trabeculectomy surgery.", + "The patient underwent phacoemulsification.", + "The patient underwent PCIOL.", + "After a 4-year follow-up, a decline in visual acuity occurred in the right eye.", + "The decline in visual acuity was due to the location of opaque fluid in the visual axis.", + "The decline in visual acuity was due to distension of the capsular bag.", + "The initial course of action was to release the trapped fluid.", + "Nd: YAG laser capsulotomy could not be employed.", + "Nd: YAG laser capsulotomy could not be employed due to the non-dilating pupil.", + "Nd: YAG laser capsulotomy could not be employed due to the high extension of the posterior capsule.", + "Anterior capsule peeling was performed.", + "Anterior segment vitrectomy surgery was performed.", + "The depth of the anterior chamber (ACD) was measured before and after surgery.", + "The distance between the face of the retro-IOL and the posterior capsule was measured before and after surgery.", + "Best-corrected visual acuity (BCVA) was measured before and after surgery.", + "Visual quality (VQ) was measured before and after surgery.", + "Inflammatory cytokine levels in the opaque substances were assessed using a flow cytometer.", + "The patient experienced a significant improvement in BCVA after surgery.", + "The patient experienced a significant improvement in VQ after surgery.", + "The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing after surgery.", + "ACD did not differ between pre- and post-operatively.", + "IL-8 concentrations were higher in the OS than in aqueous humor.", + "BFGF concentrations were higher in the OS than in aqueous humor.", + "VCAM concentrations were lower in the OS than in aqueous humor." + ] + }, + { + "id": "multiclinsum_test_3046_en.txt", + "fulltext": "A 74-year-old male patient with chronic kidney disease stage III, essential hypertension, coronary artery disease with 30% stenosis of the RCA, atrial fibrillation on chronic anticoagulation, rhythm control with amiodarone, rate control with diltiazem, and implantable defibrillator, who had a history of self-resolved upper respiratory infection a week prior to admission, when he started experiencing shortness of breath (SOB).\n\nShortness of breath was evident during exertion and at rest, presenting with orthopnea and paroxysmal nocturnal dyspnea. His symptoms were accompanied by intermittent chest discomfort and pressure lasting around 15 minutes, worse when laying supine, attenuated by sitting up, non-radiating, and not accompanied by diaphoresis, and self-resolving. He did not take any medications to alleviate discomfort. He mentioned experiencing chills, diaphoresis, nasal congestion, sore throat, arthralgia, unexpected weight loss, and occasional dizziness and imbalance while walking. The day before admission, he could walk his dog for 1 block; on admission day, he could not walk due to persistent SOB. He denied having any fever, cough, hemoptysis, palpitations, edema, muscle, or joint discomfort.\n\nOn physical examination his vital signs demonstrated heart rate 74 beats per minute, blood pressure 159/69 mmHg, respiratory rate 20, O2 sat above 94% on room air.\n\nHe was in respiratory distress and his cardiovascular assessment revealed distant heart sounds, absence of JVD, abdominal tenderness in the right upper quadrant and epigastric area, as well as malleolar pitting edema.\n\nElectrocardiogram demonstrated sinus rhythm, 70 bpm, prolonged PR, low voltage in precordial leads, and prolonged QTc.\n\nFindings such as muffled heart sounds, low voltage ECG, and cardiomegaly lead to the decision of performing POCUS at bedside. It demonstrated a large pericardial effusion.\n\nChest x-ray demonstrated cardiomegaly, with no evidence of infiltrates or vascular cephalization.\n\n2D-echocardiogram STAT was performed, and cardiology was consulted due to high suspicion of tamponade after POCUS, despite the patient’s adequate vital signs.\n\nHe was admitted due to dyspnea secondary to pericardial effusion, ruling out cardiac tamponade and transaminitis of unclear source. A couple of hours after admission, the patient became hemodynamically unstable secondary to cardiogenic shock.\n\nEmergent pericardiocentesis was performed in the ICU by cardiologist with removal of 800 mL of dark purple bloody pericardial fluid. Pericardial window was performed, draining the remaining pericardial effusion (700 mL of bloody, nonclotting fluid); the pericardium and epicardium were extremely inflamed. No isolated source of bleeding; however, some areas of oozing.\n\nInitial 2D-echo demonstrated right atrial invagination and 0.39% inspiratory to expiratory respiratory variation in mitral inflow velocities, consistent with tamponade.\n\nPathology report of pericardial tissue—benign fibrovascular adipose tissue with reactive fibro-cellular changes, patchy chronic-acute inflammation, and focal fat necrosis. No evidence of malignancy.", + "fulltext_subclaims": [ + "The patient is a 74-year-old male.", + "The patient has chronic kidney disease stage III.", + "The patient has essential hypertension.", + "The patient has coronary artery disease with 30% stenosis of the RCA.", + "The patient has atrial fibrillation.", + "The patient is on chronic anticoagulation.", + "The patient is on rhythm control with amiodarone.", + "The patient is on rate control with diltiazem.", + "The patient has an implantable defibrillator.", + "The patient had a history of self-resolved upper respiratory infection a week prior to admission.", + "The patient started experiencing shortness of breath.", + "Shortness of breath was evident during exertion and at rest.", + "The patient had orthopnea.", + "The patient had paroxysmal nocturnal dyspnea.", + "The patient had intermittent chest discomfort and pressure lasting around 15 minutes.", + "The chest discomfort was worse when laying supine.", + "The chest discomfort was attenuated by sitting up.", + "The chest discomfort was non-radiating.", + "The chest discomfort was not accompanied by diaphoresis.", + "The chest discomfort was self-resolving.", + "The patient did not take any medications to alleviate discomfort.", + "The patient mentioned experiencing chills.", + "The patient mentioned experiencing diaphoresis.", + "The patient mentioned experiencing nasal congestion.", + "The patient mentioned experiencing sore throat.", + "The patient mentioned experiencing arthralgia.", + "The patient mentioned experiencing unexpected weight loss.", + "The patient mentioned experiencing occasional dizziness and imbalance while walking.", + "The patient could walk his dog for 1 block the day before admission.", + "The patient could not walk due to persistent SOB on admission day.", + "The patient denied having any fever.", + "The patient denied having any cough.", + "The patient denied having any hemoptysis.", + "The patient denied having any palpitations.", + "The patient denied having any edema.", + "The patient denied having any muscle or joint discomfort.", + "On physical examination, the heart rate was 74 beats per minute.", + "On physical examination, the blood pressure was 159/69 mmHg.", + "On physical examination, the respiratory rate was 20.", + "On physical examination, the O2 saturation was above 94% on room air.", + "The patient was in respiratory distress.", + "The cardiovascular assessment revealed distant heart sounds.", + "The cardiovascular assessment revealed absence of JVD.", + "The abdominal examination revealed tenderness in the right upper quadrant.", + "The abdominal examination revealed tenderness in the epigastric area.", + "The patient had malleolar pitting edema.", + "The electrocardiogram demonstrated sinus rhythm.", + "The electrocardiogram demonstrated a heart rate of 70 bpm.", + "The electrocardiogram demonstrated prolonged PR interval.", + "The electrocardiogram demonstrated low voltage in precordial leads.", + "The electrocardiogram demonstrated prolonged QTc.", + "Findings such as muffled heart sounds, low voltage ECG, and cardiomegaly led to the decision of performing POCUS at bedside.", + "POCUS demonstrated a large pericardial effusion.", + "Chest x-ray demonstrated cardiomegaly.", + "Chest x-ray showed no evidence of infiltrates.", + "Chest x-ray showed no evidence of vascular cephalization.", + "A 2D-echocardiogram STAT was performed.", + "Cardiology was consulted due to high suspicion of tamponade after POCUS.", + "The patient was admitted due to dyspnea secondary to pericardial effusion.", + "The patient was admitted to rule out cardiac tamponade.", + "The patient was admitted to rule out transaminitis of unclear source.", + "A couple of hours after admission, the patient became hemodynamically unstable secondary to cardiogenic shock.", + "Emergent pericardiocentesis was performed in the ICU by a cardiologist.", + "800 mL of dark purple bloody pericardial fluid was removed.", + "A pericardial window was performed, draining the remaining pericardial effusion.", + "700 mL of bloody, nonclotting fluid was drained.", + "The pericardium and epicardium were extremely inflamed.", + "No isolated source of bleeding was found.", + "Some areas of oozing were noted.", + "Initial 2D-echo demonstrated right atrial invagination.", + "Initial 2D-echo demonstrated 0.39% inspiratory to expiratory respiratory variation in mitral inflow velocities.", + "The 2D-echo findings were consistent with tamponade.", + "The pathology report of pericardial tissue showed benign fibrovascular adipose tissue.", + "The pathology report showed reactive fibro-cellular changes.", + "The pathology report showed patchy chronic-acute inflammation.", + "The pathology report showed focal fat necrosis.", + "The pathology report showed no evidence of malignancy." + ], + "summary": "We present the case of a 74-year-old male with a history of upper respiratory infection who developed sudden onset dyspnea and chest discomfort. Bedside point-of-care ultrasound (POCUS) revealed a large pericardial effusion, prompting urgent intervention. Despite initially stable vital signs, the patient rapidly deteriorated, necessitating emergent pericardiocentesis. Laboratory findings and pathology results eventually ruled out common viral causes, guiding diagnosis toward coxsackieviruses A and B, echovirus, adenoviruses, or influenza.", + "summary_subclaims": [ + "The patient is a 74-year-old male.", + "The patient has a history of upper respiratory infection.", + "The patient developed sudden onset dyspnea.", + "The patient had chest discomfort.", + "Bedside point-of-care ultrasound revealed a large pericardial effusion.", + "The patient underwent emergent pericardiocentesis.", + "Laboratory findings and pathology results ruled out common viral causes.", + "The diagnosis was guided toward coxsackieviruses A and B, echovirus, adenoviruses, or influenza." + ] + }, + { + "id": "multiclinsum_test_1462_en.txt", + "fulltext": "A 51-year-old HIV-positive homosexual man, who has been followed at our hospital since 1992 for HIV, was admitted in June 2004 for persistent low-grade fever, night sweats and a 12 kilogram weight loss over one year. He was treated with antiretroviral therapy since 1995 and HAART since 1997. Unfortunately, the emergence of HIV variants with multiple resistance gene mutations resulted in a high HIV load and low CD4+ T cell count. At the time of admission, the patient's CD4+ T cell count was 8 cells/μl, and his HIV RNA level was 792,000 copies/ml. The body temperature ranged from 37°C to 38°5C. Physical examination revealed an enlarged liver and an extensive well-demarcated, violaceous plaque on the left ankle with 5 additional small violaceous nodules disseminated on the head, trunk and left leg, suggesting a diagnosis of bacillary angiomatosis (BA). A chest CT scan revealed a left lower-lobe density and sputum smears were positive for acid-fast bacilli (AFB). Pelvic CT scan revealed an inflammatory swelling within the right gluteus muscle that was biopsied as were the cutaneous lesion of the left ankle and the bone marrow.", + "fulltext_subclaims": [ + "The patient is a 51-year-old HIV-positive homosexual man.", + "He has been followed at our hospital since 1992 for HIV.", + "He was admitted in June 2004.", + "He had persistent low-grade fever.", + "He had night sweats.", + "He had a 12 kilogram weight loss over one year.", + "He was treated with antiretroviral therapy since 1995.", + "He was treated with HAART since 1997.", + "The emergence of HIV variants with multiple resistance gene mutations resulted in a high HIV load and low CD4+ T cell count.", + "At the time of admission, the patient's CD4+ T cell count was 8 cells/μl.", + "At the time of admission, his HIV RNA level was 792,000 copies/ml.", + "The body temperature ranged from 37°C to 38.5°C.", + "Physical examination revealed an enlarged liver.", + "Physical examination revealed an extensive well-demarcated, violaceous plaque on the left ankle.", + "Physical examination revealed 5 additional small violaceous nodules disseminated on the head, trunk and left leg.", + "The findings suggested a diagnosis of bacillary angiomatosis.", + "A chest CT scan revealed a left lower-lobe density.", + "Sputum smears were positive for acid-fast bacilli.", + "A pelvic CT scan revealed an inflammatory swelling within the right gluteus muscle.", + "The cutaneous lesion of the left ankle was biopsied.", + "The bone marrow was biopsied." + ], + "summary": "We report the case of an AIDS patient with a primary clinical presentation suggestive of bacillary angiomatosis. We also found in cutaneous lesions Mycobacterium avium complex and cytomegalovirus.", + "summary_subclaims": [ + "We report the case of an AIDS patient.", + "The patient had a primary clinical presentation suggestive of bacillary angiomatosis.", + "Cutaneous lesions were found.", + "Mycobacterium avium complex was found in cutaneous lesions.", + "Cytomegalovirus was found in cutaneous lesions." + ] + }, + { + "id": "multiclinsum_test_1828_en.txt", + "fulltext": "A 72-year-old female, fully edentulous, wearing a removable prosthesis, was referred to our clinic after three unsuccessful attempts at rehabilitation of the edentulous mandible, with complete dentures. The patient had a 16-month history of swallowing problems, a painful erosion lesion, burning sensations on the left floor of the mouth, and recurrent numbness in the lower-right inferior lip. The X-ray evaluation showed extreme resorption of the mandible, as seen in Fig. .\nThe patient was content with her maxillary denture, which was satisfactory from a technical point of view.\nHer medical history revealed type 2 diabetes mellitus managed with medication, psychological depression, class II obesity, obstructive sleep apnea, class III (moderate) to IV (severe) heart failure according to NYHA (New York Heart Association) classification, controlled essential hypertension, and ischemic heart disease.\nThe preoperative CBCT confirmed resorption of the alveolar bone and partial resorption of the basal bone, a residual bone height between 5 and 8 mm corresponding to the interforaminal region, and the exposure of the inferior alveolar nerve (Class V-VI according to Cawood and Howell classification ), with no residual bone above the nerve in the lateral region (between the mental foramen and the second molar).\nAfter presenting all the available options, including mental nerve transposition and extensive bone grafting, the accepted and less-invasive treatment was an overdenture supported by four splinted dental implants, without any bone grafting. The insertion of only two interforaminal implants was excluded due to the high risk of mandibular fracture. Therefore, in the third molar region, the inferior alveolar nerve by-pass technique was considered to be appropriate in this case. Prophylactic antibiotic therapy was initiated within one hour before surgery; the patient was administered with 2 g of a combination of amoxicillin and potassium clavulanate.\nMepivacaine HCl 3 % without vasoconstrictor (Scandonest 3 %, Septodont, Saint-Maur-des-Fossés, France) was locally infiltrated into the lingual and the labial aspect for each implant site. A full muco-periosteal flap was elevated to obtain direct visual access to the residual bone.\nThe osteotomies were performed at 300 rpm and 50Ncm under cold saline irrigation using a freehand technique. In the interforaminal region, two 3.5 mm x 7mm implants (AnyRidge®, MegaGen, Daegu, Korea) were placed with an insertion torque of 40Ncm (right) and 45 Ncm (left), respectively. In the third molar area, two 3.2 mm x 10 mm implants (Mini®, MegaGen, Daegu, Korea) were placed with an insertion torque of 35 Ncm. The implants were inserted in the residual buccal bone bypassing the inferior alveolar nerve, as shown in Fig. A and B.\nThe healing abutments were installed immediately: two conventional in the anterior region and two custom made; 12 mm in length healing in the posterior mandible. Simple interrupted sutures were used to close the incisions. 2 g of amoxicillin and clavulanate potassium were administered for the following 4 days. Sensory condition in the lower lip and chin was evaluated 24 h after the surgery, and no neurosensory changes were present. Healing was uneventful and the sutures were removed 14 days after surgery. Restorative treatment was initiated at 22 weeks post-implant insertion and the patient received the final overdenture 22 days after the preliminary impression.\nDue to the high level of mandibular atrophy, a special three-part customized impression tray was made as shown in Fig. A and B. The corresponding transfer abutments, AnyRidge®, for the two interforaminal implants, and Mini®, for the posterior implants, were inserted and functional impressions were taken with a polyether material (Impregum; 3 M ESPE, St. Paul, MN, USA), as shown in Fig. A. The three-part customised tray was made on a preliminary cast with implant analogues poured from a preliminary impression with the corresponding transfer abutments. Jaw relations were recorded with record bases and occlusal rims as shown in Figs. and A and C.\nAn Artex face bow (Amann Girrbach, Koblach, Austria) was used to transfer the horizontal relationship of the maxillary arch to the cranial base and data were employed to mount maxillary and mandibular casts in an Artex®CR (Amann Girrbach AG, Koblach, Austria) -Arcon articulator, following the manufacturer’s instructions. A try-in mandibular denture was manufactured and the required functional adjustments were performed, as shown in Fig. B. A removable bar-retained overdenture was planned. Four OT Equator® abutments (Rhein83, Bologna, Italy) were screwed onto the implants, two custom-made 11 mm abutments on the posterior implants and two 4 mm abutments in the interforaminal region.\nA custom-designed bar secured with four castable Seeger Bar containers (Rhein83, Bologna, Italy), as shown in Fig. A and B was screwed over the OT Equator® abutments, with titanium locking screws and self-extracting Seeger rings (Rhein83, Bologna, Italy). The bar’s link framework was made with castable components: OT Bar gingival connectors. To anchor the over-structure, four single OT Equator® castable retentions (Rhein83, Bologna, Italy) were placed balanced distributed on the canine-premolar regions of the bar to ensure polygonal support for the denture. Both the bar and link frameworks were cast from Cr-Co alloy, together in the same duplicating mould to equalise the volumetric changes for both structures. After casting and postprocessing, the link framework was bonded to the final denture using a light-curing resin.\nThe bar was mounted on the four OT Equator® abutments by using the self-extracting elastic Seeger rings over the abutments, with the aim to obtain a passive structure and avoid stress distribution to the dental implants . Also, the space between the bar and the underlying mucosa was designed adequately for oral hygiene maintenance .\nDue to the pattern of atrophy, the distal parts of the bar were not covered by the mandibular overdenture, as shown in Fig. A-D.\nAt the delivery of the denture, functional adjustments were performed, and soft retention Nylon inserts were used. Oral hygiene instructions, including the use of interproximal brushes and oral irrigators, were provided to the patient. The patient was extremely happy with the functional and aesthetic outcomes, as shown in Fig. A and B. The correct positioning of the bar was assessed with the aid of an orthopantomography, as shown in Fig. .\nAt one week post denture insertion follow-up, the patient had normal lower-lip sensitivity, improved masticatory ability, and normal deglutition.\nThe patient’s self-perception in relation to the impacts of oral conditions on physical, psychological, and social wellbeing was evaluated before treatment and one week post mandibular overdenture insertion using the Oral Health Impact Profile for Edentulous Patients (OHIP-EDENT) questionnaire, validated for the Romanian language (ClinicalTrials.gov Identifier: NCT01392456). Each of the 19 items were assessed on a Likert scale (4 = always, 3 = frequently, 2 = sometimes, 1 = seldom, and 0 = never) with a total range of 0–76, a higher score meaning poorer quality of life . Despite the good fit of the maxillary denture, the registered OHIP-EDENT total score was 69 prior to the treatment; however, it decreased to 19 with the final mandibular overdenture, showing a significant improvement in quality of life.\nAt the 14-month follow-up, the overdenture was evaluated and a CBCT taken, as shown in Fig. . The inferior alveolar nerve integrity and the stability of the bone tissue surrounding the dental implants were also assessed.", + "fulltext_subclaims": [ + "The patient was a 72-year-old female.", + "The patient was fully edentulous.", + "The patient was wearing a removable prosthesis.", + "The patient had three unsuccessful attempts at rehabilitation of the edentulous mandible.", + "The patient had a 16-month history of swallowing problems.", + "The patient had a painful erosion lesion.", + "The patient had burning sensations on the left floor of the mouth.", + "The patient had recurrent numbness in the lower-right inferior lip.", + "X-ray evaluation showed extreme resorption of the mandible.", + "The patient was content with her maxillary denture.", + "The maxillary denture was satisfactory from a technical point of view.", + "The patient had type 2 diabetes mellitus managed with medication.", + "The patient had psychological depression.", + "The patient had class II obesity.", + "The patient had obstructive sleep apnea.", + "The patient had class III (moderate) to IV (severe) heart failure according to NYHA classification.", + "The patient had controlled essential hypertension.", + "The patient had ischemic heart disease.", + "Preoperative CBCT confirmed resorption of the alveolar bone.", + "Preoperative CBCT showed partial resorption of the basal bone.", + "The residual bone height was between 5 and 8 mm in the interforaminal region.", + "The inferior alveolar nerve was exposed (Class V-VI according to Cawood and Howell classification).", + "There was no residual bone above the nerve in the lateral region.", + "The accepted treatment was an overdenture supported by four splinted dental implants.", + "The treatment did not include bone grafting.", + "The insertion of only two interforaminal implants was excluded due to the high risk of mandibular fracture.", + "The inferior alveolar nerve by-pass technique was considered appropriate.", + "Prophylactic antibiotic therapy was initiated within one hour before surgery.", + "The patient was administered 2 g of a combination of amoxicillin and potassium clavulanate.", + "Mepivacaine HCl 3 % without vasoconstrictor was locally infiltrated into the lingual and labial aspect for each implant site.", + "A full muco-periosteal flap was elevated.", + "Osteotomies were performed at 300 rpm and 50Ncm under cold saline irrigation.", + "Osteotomies were performed using a freehand technique.", + "In the interforaminal region, two 3.5 mm x 7 mm implants were placed.", + "In the interforaminal region, the right implant had an insertion torque of 40Ncm.", + "In the interforaminal region, the left implant had an insertion torque of 45Ncm.", + "In the third molar area, two 3.2 mm x 10 mm implants were placed.", + "In the third molar area, the implants had an insertion torque of 35Ncm.", + "The implants were inserted in the residual buccal bone bypassing the inferior alveolar nerve.", + "Healing abutments were installed immediately.", + "Two conventional healing abutments were used in the anterior region.", + "Two custom-made healing abutments were used in the posterior mandible.", + "The healing abutments were 12 mm in length.", + "Simple interrupted sutures were used to close the incisions.", + "2 g of amoxicillin and clavulanate potassium were administered for the following 4 days.", + "Sensory condition in the lower lip and chin was evaluated 24 h after the surgery.", + "No neurosensory changes were present.", + "Healing was uneventful.", + "Sutures were removed 14 days after surgery.", + "Restorative treatment was initiated at 22 weeks post-implant insertion.", + "The patient received the final overdenture 22 days after the preliminary impression.", + "A special three-part customized impression tray was made.", + "Transfer abutments were inserted for the two interforaminal implants.", + "Transfer abutments were inserted for the posterior implants.", + "Functional impressions were taken with a polyether material.", + "An Artex face bow was used to transfer the horizontal relationship of the maxillary arch to the cranial base.", + "Maxillary and mandibular casts were mounted in an Artex®CR articulator.", + "A try-in mandibular denture was manufactured.", + "Functional adjustments were performed.", + "A removable bar-retained overdenture was planned.", + "Four OT Equator® abutments were screwed onto the implants.", + "Two custom-made 11 mm abutments were used on the posterior implants.", + "Two 4 mm abutments were used in the interforaminal region.", + "A custom-designed bar was secured with four castable Seeger Bar containers.", + "The bar was screwed over the OT Equator® abutments.", + "The bar’s link framework was made with castable components.", + "Four single OT Equator® castable retentions were placed on the canine-premolar regions of the bar.", + "The bar and link frameworks were cast from Cr-Co alloy.", + "The link framework was bonded to the final denture using a light-curing resin.", + "The bar was mounted on the four OT Equator® abutments using self-extracting elastic Seeger rings.", + "The space between the bar and the underlying mucosa was designed adequately for oral hygiene maintenance.", + "The distal parts of the bar were not covered by the mandibular overdenture.", + "Soft retention Nylon inserts were used.", + "Oral hygiene instructions were provided to the patient.", + "The patient was extremely happy with the functional and aesthetic outcomes.", + "The correct positioning of the bar was assessed with the aid of an orthopantomography.", + "At one week post denture insertion follow-up, the patient had normal lower-lip sensitivity.", + "At one week post denture insertion follow-up, the patient had improved masticatory ability.", + "At one week post denture insertion follow-up, the patient had normal deglutition.", + "The patient’s self-perception was evaluated using the OHIP-EDENT questionnaire.", + "The OHIP-EDENT questionnaire was validated for the Romanian language.", + "The OHIP-EDENT total score was 69 prior to the treatment.", + "The OHIP-EDENT total score decreased to 19 with the final mandibular overdenture.", + "At the 14-month follow-up, the overdenture was evaluated.", + "A CBCT was taken at the 14-month follow-up.", + "The inferior alveolar nerve integrity was assessed.", + "The stability of the bone tissue surrounding the dental implants was assessed." + ], + "summary": "This clinical report describes the rehabilitation of an extremely atrophic mandible using an overdenture supported by four splinted implants, two of which are placed in the interforaminal region and the other two bypassing the inferior alveolar nerve at the level of the antegonial notch. A passive-fit bar structure splinting the four inserted implants was designed to compensate for mandibular flexure, to reduce the amount of strain on the implants, and avoid bone resorption and prosthetic failure. The 14-month postoperative cone-beam computed tomography (CBCT) and the clinical follow-up showed the bilateral integrity of the inferior alveolar nerve and the successful restoration of the atrophic edentulous mandible with a significant improvement in the patient's quality of life.", + "summary_subclaims": [ + "The clinical report describes the rehabilitation of an extremely atrophic mandible using an overdenture supported by four splinted implants.", + "Two of the four implants are placed in the interforaminal region.", + "The other two implants bypass the inferior alveolar nerve at the level of the antegonial notch.", + "A passive-fit bar structure splinting the four inserted implants was designed.", + "The purpose of the bar structure was to compensate for mandibular flexure.", + "The bar structure was designed to reduce the amount of strain on the implants.", + "The bar structure was designed to avoid bone resorption and prosthetic failure.", + "The 14-month postoperative cone-beam computed tomography (CBCT) showed the bilateral integrity of the inferior alveolar nerve.", + "The clinical follow-up showed the successful restoration of the atrophic edentulous mandible.", + "The patient experienced a significant improvement in quality of life." + ] + }, + { + "id": "multiclinsum_test_1240_en.txt", + "fulltext": "A 14-year-old iTaukei (indigenous Fijian) girl presented to our hospital with a 1-month history of abdominal pain. Two days prior to her admission, her abdominal pain became worse, especially after movement, and was relieved by lying down. She also developed a high-grade fever and nausea and had one episode of vomiting. She gave no history of cough, diarrhea, vomiting, or dysuria. Her last menstrual period was on 28/9/2017. She denied any history of sexual intercourse.\nShe was referred to a nearby hospital, where ultrasonography showed a cystic structure measuring 4.9 cm × 4.4 cm at the right adnexal region. Minimal free fluid was seen in the pouch of Douglas. No obvious appendix abnormality was seen, and other structures, including the uterus, were normal. She was then transferred to one of the main hospitals in Fiji for further investigation and management.\nThe patient’s past medical history was unremarkable. She had no record of previous admission. She had not been receiving any regular medication and had no known allergies.\nThe patient resides in a village that is approximately a 45-minute drive from the nearest town. She lives in a two-bedroom corrugated house with her parents and three younger siblings. Her usual diet consists of boiled root crops (such as cassava and taro), local vegetables, and fish. The water source is a spring that supplies the whole village. The family uses a water seal toilet. She gave no history of travel outside her village in 2017.\nOn examination at the main hospital, the patient looked unwell. Her pulse was 116 beats per minute, blood pressure 114/60 mmHg, respiratory rate 21 breaths per minute, and temperature 38.8 °C. The results of her chest and cardiovascular examinations were normal. Abdominal examination revealed generalized tenderness on light palpation. However, there was no guarding or rebound tenderness, and no mass was palpable. The result of the per rectal examination was normal, as was the remaining examination.\nBlood tests revealed a hemoglobin of 9.8 g/dl (normal range [NR] 11.5–18.5 g/dl) and white blood cell count of 14,100 cells/mm3 (NR 4000–11,000 cells/mm3). Two blood cultures revealed no growth after 48 hours. The patient’s full blood count, liver and renal function, and serum electrolyte test results are shown in Table . The results of her chest and abdominal x-ray were normal.\nExploratory laparotomy revealed serosal appendicitis with erythema and abundant fibrinous peritoneal fluid; hence, an appendicectomy was performed. It was noted that the right ovary was enlarged and had ruptured because of pus collection. The right ovary was incised, and pus was drained. This pus was cultured and yielded a pure growth of Salmonella Typhi , which was identified by using Microbact™ 12A/12B identification kits (Oxoid Microbiology Products, Altrincham, UK). This identification was later confirmed by Salmonella-specific antiserum testing (Difco™; Becton, Dickinson and Company, Franklin Lakes, NJ, USA). The antimicrobial sensitivity test was performed using a disk diffusion method on Mueller-Hinton agar. The organism was susceptible to all tested antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, gentamicin, cephalothin, ceftriaxone, ciprofloxacin, and nalidixic acid). Histopathology of the resected appendix revealed reactive lymphoid follicle in mucosa and acute inflammation on the serosal layer, compatible with periappendicitis.\nThe patient was treated with intravenous ceftriaxone 1 g twice daily, cloxacillin 1 g four times daily, and metronidazole 500 mg three times daily for 5 days. She made an uneventful recovery and was discharged to home on the sixth postoperative day to complete a further 8 days of oral cotrimoxazole. Patient was reviewed 1 week after her discharge from the hospital. She did not have any complaint; her surgical wound was clean; and there were no remarkable physical findings. The result of her stool culture after completion of treatment was negative for Salmonella.", + "fulltext_subclaims": [ + "The patient is a 14-year-old iTaukei girl.", + "She had a 1-month history of abdominal pain.", + "Her abdominal pain became worse two days prior to admission.", + "The pain was relieved by lying down.", + "She developed a high-grade fever.", + "She had one episode of vomiting.", + "She denied any history of cough.", + "She denied any history of dysuria.", + "Her last menstrual period was on 28/9/2017.", + "She denied any history of sexual intercourse.", + "Ultrasonography showed a cystic structure measuring 4.9 cm × 4.4 cm at the right adnexal region.", + "Minimal free fluid was seen in the pouch of Douglas.", + "No obvious appendix abnormality was seen.", + "She was transferred to one of the main hospitals in Fiji.", + "The patient’s past medical history was unremarkable.", + "She had no record of previous admission.", + "She had not been receiving any regular medication.", + "She lives in a village approximately a 45-minute drive from the nearest town.", + "The family uses a water seal toilet.", + "She gave no history of travel outside her village in 2017.", + "On examination, her temperature was 38.8 °C.", + "Abdominal examination revealed generalized tenderness on light palpation.", + "There was no guarding or rebound tenderness.", + "Blood tests revealed a hemoglobin of 9.8 g/dl.", + "Blood tests revealed a white blood cell count of 14,100 cells/mm3.", + "Two blood cultures revealed no growth after 48 hours.", + "Exploratory laparotomy revealed serosal appendicitis with erythema.", + "An appendicectomy was performed.", + "The right ovary was enlarged and had ruptured because of pus collection.", + "Pus cultured yielded a pure growth of Salmonella Typhi.", + "The organism was identified using Microbact™ 12A/12B identification kits.", + "The identification was confirmed by Salmonella-specific antiserum testing.", + "The organism was susceptible to all tested antibiotics.", + "The patient was treated with intravenous ceftriaxone 1 g twice daily.", + "The patient was treated with cloxacillin 1 g four times daily.", + "The patient was treated with metronidazole 500 mg three times daily for 5 days.", + "She was discharged on the sixth postoperative day.", + "She was to complete a further 8 days of oral cotrimoxazole.", + "She was reviewed 1 week after discharge.", + "The result of her stool culture after completion of treatment was negative for Salmonella." + ], + "summary": "A 14-year-old iTaukei (indigenous Fijian) girl presented to our hospital with abdominal pain of 1 month's duration. Two days prior to her admission, she developed high-grade fever and nausea and had one episode of vomiting. On presentation, she appeared unwell; she was tachycardic (116 beats per minute) and febrile (38.8 °C). Her abdominal examination revealed generalized tenderness. Other examination findings were normal. The provisional diagnosis of abdominal sepsis led to an emergency laparotomy during which an enlarged right ovary was found to be spontaneously discharging pus. The ovary was incised and drained, and the patient was commenced on intravenous ceftriaxone 1 g twice daily, cloxacillin 1 g four times daily, and metronidazole 500 mg three times daily. She recovered promptly and was discharged to home on the sixth postoperative day. The purulent material from the ovary grew Salmonella Typhi.", + "summary_subclaims": [ + "The patient is a 14-year-old iTaukei girl.", + "She had abdominal pain for 1 month.", + "Two days before admission, she developed high-grade fever.", + "She had one episode of vomiting.", + "On presentation, she was tachycardic at 116 beats per minute.", + "Her temperature was 38.8 °C.", + "The provisional diagnosis was abdominal sepsis.", + "An emergency laparotomy was performed.", + "An enlarged right ovary was found to be spontaneously discharging pus.", + "The ovary was incised and drained.", + "She was started on intravenous ceftriaxone 1 g twice daily.", + "She was started on intravenous cloxacillin 1 g four times daily.", + "She was started on intravenous metronidazole 500 mg three times daily.", + "She was discharged on the sixth postoperative day.", + "The purulent material from the ovary grew Salmonella Typhi." + ] + }, + { + "id": "multiclinsum_test_1877_en.txt", + "fulltext": "A 55-year-old female experiencing a progressive headache and vomiting for one month was admitted to our hospital.\n55-year-old female experiencing a progressive headache and vomiting for one month was admitted to our hospital. She was diagnosed with lung adenocarcinoma with osseous metastasis 10 mo prior to admittance. EGFR mutation was detected upon genomic examination, so she was first treated with gefitinib for 10 mo before acquiring resistance. A previous enhanced cerebral magnetic resonance imaging (MRI) and PET-CT one month prior showed that there was no obvious abnormality in the CNS. Lumbar puncture showed an increased intracranial pressure (+ACY-gt+ADs-330 mmH2O) without positive cytology and biochemical examination findings in the CSF. However, further CSF ctDNA detection by next-generation sequencing showed an EGFR-Thr790Met mutation. After the patient was admitted, a second enhanced MRI was performed and showed comprehensive linear leptomeningeal enhancement in the cerebral sulcus . A second cytology and biochemical examination of the CSF remained negative.\nThe patient had no special history of past illness other than a hysterectomy procedure for fibroids 10 years prior.\nThe patient had no special history of past illness other than a hysterectomy procedure for fibroids 10 years prior.\nNeurological and pulmonary examination of the patient showed no obvious abnormalities.\nLumbar puncture showed an increased intracranial pressure (> 330 mmH2O) without positive cytology and biochemical examination findings in CSF. However, further CSF ctDNA detection by next-generation sequencing showed an EGFR-Thr790Met mutation, and the variation frequency was 11.7%.\n(1) Chest CT image at admission shows a lesion in the lingual segment of the upper lobe of the left lung (arrows); and (2) A follow-up cerebral contrast-enhanced MRI shows diffuse and linear enhancement along the surface of the cerebrum (arrows).", + "fulltext_subclaims": [ + "A 55-year-old female experiencing a progressive headache and vomiting for one month was admitted to our hospital.", + "She was diagnosed with lung adenocarcinoma with osseous metastasis 10 mo prior to admittance.", + "EGFR mutation was detected upon genomic examination.", + "She was first treated with gefitinib for 10 mo before acquiring resistance.", + "A previous enhanced cerebral magnetic resonance imaging (MRI) and PET-CT one month prior showed that there was no obvious abnormality in the CNS.", + "Lumbar puncture showed an increased intracranial pressure (+ACY-gt+ADs-330 mmH2O) without positive cytology and biochemical examination findings in the CSF.", + "Further CSF ctDNA detection by next-generation sequencing showed an EGFR-Thr790Met mutation.", + "A second enhanced MRI was performed and showed comprehensive linear leptomeningeal enhancement in the cerebral sulcus.", + "A second cytology and biochemical examination of the CSF remained negative.", + "The patient had no special history of past illness other than a hysterectomy procedure for fibroids 10 years prior.", + "Neurological and pulmonary examination of the patient showed no obvious abnormalities.", + "Lumbar puncture showed an increased intracranial pressure (> 330 mmH2O) without positive cytology and biochemical examination findings in CSF.", + "Further CSF ctDNA detection by next-generation sequencing showed an EGFR-Thr790Met mutation, and the variation frequency was 11.7%.", + "Chest CT image at admission shows a lesion in the lingual segment of the upper lobe of the left lung.", + "A follow-up cerebral contrast-enhanced MRI shows diffuse and linear enhancement along the surface of the cerebrum." + ], + "summary": "A 55-year-old female with a progressive headache and vomiting for one month was admitted to Peking University First Hospital. She was diagnosed with lung adenocarcinoma with osseous metastasis 10 months prior to admittance. epidermal growth factor receptor (EGFR) mutation was detected by genomic examination, so she was first treated with gefitinib for 10 months before acquiring resistance. Cell-free cerebrospinal fluid (CSF) circulating tumor DNA detection by next-generation sequencing was conducted and indicated the EGFR-Thr790Met mutation, while biopsy and cytology from the patient's CSF and the first enhanced cranial magnetic resonance imaging (MRI) showed no positive findings. A month later, the enhanced MRI showed linear leptomeningeal enhancement, and the cytology and biochemical examination in CSF remained negative. Therefore, osimertinib (80 mg/d) was initiated as a second-line treatment, resulting in a good response within a month.", + "summary_subclaims": [ + "The patient is a 55-year-old female.", + "She had a progressive headache and vomiting for one month.", + "She was admitted to Peking University First Hospital.", + "She was diagnosed with lung adenocarcinoma with osseous metastasis 10 months prior to admittance.", + "epidermal growth factor receptor (EGFR) mutation was detected by genomic examination.", + "She was first treated with gefitinib for 10 months before acquiring resistance.", + "Cell-free cerebrospinal fluid (CSF) circulating tumor DNA detection by next-generation sequencing was conducted.", + "The detection indicated the EGFR-Thr790Met mutation.", + "Biopsy and cytology from the patient's CSF showed no positive findings.", + "The first enhanced cranial magnetic resonance imaging (MRI) showed no positive findings.", + "A month later, the enhanced MRI showed linear leptomeningeal enhancement.", + "The cytology and biochemical examination in CSF remained negative.", + "Osimertinib (80 mg/d) was initiated as a second-line treatment.", + "The treatment resulted in a good response within a month." + ] + }, + { + "id": "multiclinsum_test_2100_en.txt", + "fulltext": "The patient was a 67-year-old woman who was admitted to the clinic in September 2019.\nThe patient was suffering lumbar pain for 7 years and aggravation with interspace claudication since the preceding February.\nTwenty years previously, the patient had undergone partial thyroidectomy for thyroid nodules at a primary hospital. Post-operative examination of the resected specimen suggested a benign thyroid lesion.\nThe patient had no history of food or drug allergies, and genetic diseases.\nPhysical examination revealed mild limitation of lumbar flexion and extension activity, L4 paravertebral tenderness, no obvious abnormalities in sensation/movement, and normal blood circulation in both lower limbs. The results of the straight leg raising test, strength test, and bilateral Patrick's sign were negative. No abnormal nodules were touch in the bilateral thyroid glands, and cervical lymph nodes showed no enlargement bilaterally.\nColor ultrasonography indicated solid nodules in the middle of the right lobe of the thyroid, thyroid imaging reporting and data system (TI-RADS) category 4A, and hypoechoic nodules in the bilateral lobes of the thyroid gland, TI-RADS category 3. Therefore, a nodular goiter was considered. No abnormal enlargement of the bilateral cervical lymph nodes was observed. Lumbar computed tomography (CT) and magnetic resonance imaging (MRI) results suggested metastatic or malignant tumors . Thyroid fine-needle aspiration demonstrated a large number of red blood cells (RBCs) with benign proliferative follicular epithelial cells. Thyroid needle biopsy results indicated a small number of thyroid follicles with nodular hyperplasia. Pathological examination of the L4 vertebral puncture biopsy indicated fibrinoid necrosis, broken bone, and thyroid tissue, which suggested metastatic thyroid cancer. Therefore, we sent the sample for pathological consultation at the Shantou University Medical College. Their examination indicated that bone marrow tissue, bone trabecula, and thyroid follicular tissue were observed in the puncture tissue of the L4 vertebral body. Considering the potential for ectopic thyroid tissue, we wanted to exclude FTC. Thyroid function was normal. However, MRI of the lumbar spine indicated malignancy, and whole-body positron emission tomography (PET)-CT was consistent with spinal tumors. No other metastases were found .", + "fulltext_subclaims": [ + "The patient was a 67-year-old woman.", + "The patient was admitted to the clinic in September 2019.", + "The patient was suffering lumbar pain for 7 years.", + "The patient had aggravation with interspace claudication since the preceding February.", + "Twenty years previously, the patient had undergone partial thyroidectomy for thyroid nodules at a primary hospital.", + "Post-operative examination of the resected specimen suggested a benign thyroid lesion.", + "The patient had no history of food or drug allergies.", + "The patient had no history of genetic diseases.", + "Physical examination revealed mild limitation of lumbar flexion and extension activity.", + "Physical examination revealed L4 paravertebral tenderness.", + "The results of the straight leg raising test were negative.", + "The results of the strength test were negative.", + "The results of bilateral Patrick's sign were negative.", + "Color ultrasonography indicated solid nodules in the middle of the right lobe of the thyroid.", + "Color ultrasonography indicated hypoechoic nodules in the bilateral lobes of the thyroid gland.", + "Color ultrasonography indicated TI-RADS category 4A for the solid nodules in the right lobe.", + "Color ultrasonography indicated TI-RADS category 3 for the hypoechoic nodules in the bilateral lobes.", + "Lumbar computed tomography (CT) and magnetic resonance imaging (MRI) results suggested metastatic or malignant tumors.", + "Thyroid fine-needle aspiration demonstrated a large number of red blood cells.", + "Thyroid fine-needle aspiration demonstrated benign proliferative follicular epithelial cells.", + "Thyroid needle biopsy results indicated a small number of thyroid follicles with nodular hyperplasia.", + "Pathological examination of the L4 vertebral puncture biopsy indicated fibrinoid necrosis.", + "Pathological examination of the L4 vertebral puncture biopsy indicated broken bone.", + "Pathological examination of the L4 vertebral puncture biopsy indicated thyroid tissue.", + "The sample was sent for pathological consultation at the Shantou University Medical College.", + "Their examination indicated that bone marrow tissue was observed in the puncture tissue of the L4 vertebral body.", + "Their examination indicated that bone trabecula was observed in the puncture tissue of the L4 vertebral body.", + "Their examination indicated that thyroid follicular tissue was observed in the puncture tissue of the L4 vertebral body.", + "Thyroid function was normal.", + "MRI of the lumbar spine indicated malignancy.", + "Whole-body positron emission tomography (PET)-CT was consistent with spinal tumors.", + "No other metastases were found." + ], + "summary": "We report a case of bone metastasis as the only clinical manifestation of thyroid cancer. The patient was a 67-year-old woman with lumbar pain for 7 years and aggravation with intermittent claudication who had previously undergone partial thyroidectomy of a benign thyroid lesion. No abnormal nodules were found in the bilateral thyroid glands. However, imaging studies were consistent with a spinal tumor, and the lesion was diagnosed as a metastatic follicular carcinoma of thyroid origin. We adopted a multidisciplinary collaboration and comprehensive treatment approach. The patient underwent lumbar spine surgery, total resection of the thyroid, postoperative TSH suppression therapy, and RAIT. There were no complications associated with the operation, and the patient had good postoperative recovery. She has experienced no recurrence.", + "summary_subclaims": [ + "The patient was a 67-year-old woman.", + "She had lumbar pain for 7 years.", + "She had aggravation with intermittent claudication.", + "She had previously undergone partial thyroidectomy of a benign thyroid lesion.", + "No abnormal nodules were found in the bilateral thyroid glands.", + "Imaging studies were consistent with a spinal tumor.", + "The lesion was diagnosed as a metastatic follicular carcinoma of thyroid origin.", + "We adopted a multidisciplinary collaboration and comprehensive treatment approach.", + "The patient underwent lumbar spine surgery.", + "The patient underwent total resection of the thyroid.", + "The patient received postoperative TSH suppression therapy.", + "The patient received RAIT.", + "There were no complications associated with the operation.", + "The patient had good postoperative recovery.", + "She has experienced no recurrence." + ] + }, + { + "id": "multiclinsum_test_1147_en.txt", + "fulltext": "A 5-year-old Persian, female cat was brought for investigation of progressive behavioral changes (loss appetite, loss weight, imbalance, and lethargy) at Albaittar clinic in Tripoli, Libya. The cat was mated 1 month before it was brought to the clinic. It showed vigorous behavior in a male during estrus. The cat’s owner visited the clinic for suspecting pregnancy. At presentation, the cat had a body weight of 2.5 kg and a body temperature of 38°C. Physical examination revealed an enlargement of the abdomen, with a palpable irregular-shaped mass on the right side of the mesogastric region. Abdominal Ultrasound examination (DRAMIŃSKI ANIMALprofi L, DRAMIŃSKI, Poland) revealed the presence of an echogenic irregular mass in the right ovary.\nThe cat subsequently underwent therapeutic ovariohysterectomy (OHE). Ovaries, uterus, contralateral ovary, and fallopian tube were fixed in 10% neutral buffered formalin within 48 hours and submitted for macroscopic and histopathological examination. The cat received 20 mg/kg of long-acting Amoxicillin for five consecutive days after the operation and the wound was dressed with wound disinfectant and antibiotic powder every 2 days. The cat started to eat on the next day of the operation.\nMacroscopic examination revealed a uterus measured 11 cm in length, convoluted with corkscrew appearance, soft in consistency, and intact serosal layer . The right ovary showed an attached ovarian cystic tissue mass measured 6 × 5 × 3 cm, rounded in shape, dark red to tan in color, soft to firm in consistency with multilobulation and intact capsule . The specimen was inked and serially cut. The contralateral ovary measured 0.9 cm and fallopian tube measured 0.5 cm in length.\nOn cut section of the ovarian tissue mass, a well-circumscribed multilobular tumor mass, solid heterogeneous, greyish white to tan in colored areas with multiple foci of necrosis and cystic spaces were detected. The capsule is intact grossly. The uterine cavity showed thickened wall with variable cystic dilatations. The other ovary and fallopian tube showed no obvious pathological abnormality.\nFor histopathological examination, serial sections were taken from the ovarian tumor mass and from the uterus, as well as, from the contralateral ovary and fallopian tube, and were fixed in 10% buffered formalin for later processing and examination. All histological procedures were performed according to . The tissue sections were stained with hematoxylin and eosin (H&E) following the standard procedures. The stained tissue sections were examined under a light microscope (ZEISS, Germany).\nHistopathological examination of the ovarian tumor mass revealed a malignant tumor composed of diffuse atypical granulosa cells with spherical to oval nuclei, distinct nucleoli, and scant eosinophilic cytoplasm arranged in different patterns (micro follicles, small nests, acinar formation, and alveolar-like) . Regions of the tumor exhibited Sertoli-pattern (Luteinization), while others showed sarcomatous spindle cells arranged in tight fascicles . The cells were separated by connective tissue septa along with areas of hemorrhage and necrosis . Mitotic count according to active foci of the tumor showed 2–3 mitosis / 10 hpF. The fibroconnective tissue capsule (FCC) revealed evidence of vascular invasion which showed blood vessels lined by endothelial cells .\nThe endometrium examination revealed thickened endometrial lining with elongated glands and prominent stroma. There was also a dilatation of glands with formation of variable sized cysts . No cytological atypia was seen, nor evidence of complexity or tumor deposits or invasion. The contralateral ovary and fallopian tube showed normal histological findings, with no evidence of malignant infiltrations.\nBased on histological findings, the GCT of the ovary with evidence of vascular invasion associated with CEH was made and the contralateral ovary and fallopian tube were free.\nThe surgical intervention resulted in the complete resolution of clinical signs. However, 6 months following surgery the cat was brought to the Albittar clinic again with complaints of weakness, cachexia, ascites, off food, and lethargy with the presence of abdominal mass. Sings of pain were determined on palpation of the right abdominal region and ultrasonography examination was performed. According to the ultrasonography examination, a clear mass at the mesogastric region attached to the right kidney was determined and was suspected as a sequela of past tumor metastasis. Since the poor prognosis surgery was not performed, the cat had paralysis in hind limbs and massive weight loss after one week and eventually died. The owner of the cat rejected the euthanized decision and the postmortem examination.", + "fulltext_subclaims": [ + "A 5-year-old Persian, female cat was brought for investigation of progressive behavioral changes.", + "The behavioral changes included loss of appetite, loss of weight, imbalance, and lethargy.", + "The cat was mated 1 month before it was brought to the clinic.", + "The cat showed vigorous behavior in a male during estrus.", + "The cat’s owner visited the clinic for suspecting pregnancy.", + "At presentation, the cat had a body weight of 2.5 kg.", + "At presentation, the cat had a body temperature of 38°C.", + "Physical examination revealed an enlargement of the abdomen.", + "A palpable irregular-shaped mass was found on the right side of the mesogastric region.", + "Abdominal Ultrasound examination revealed the presence of an echogenic irregular mass in the right ovary.", + "The cat underwent therapeutic ovariohysterectomy.", + "Ovaries, uterus, contralateral ovary, and fallopian tube were fixed in 10% neutral buffered formalin within 48 hours.", + "The cat received 20 mg/kg of long-acting Amoxicillin for five consecutive days after the operation.", + "The wound was dressed with wound disinfectant and antibiotic powder every 2 days.", + "The cat started to eat on the next day of the operation.", + "Macroscopic examination revealed a uterus measured 11 cm in length.", + "The uterus had a convoluted corkscrew appearance.", + "The right ovary showed an attached ovarian cystic tissue mass measured 6 × 5 × 3 cm.", + "The ovarian tissue mass was rounded in shape, dark red to tan in color, soft to firm in consistency with multilobulation and intact capsule.", + "On cut section of the ovarian tissue mass, a well-circumscribed multilobular tumor mass was detected.", + "The tumor mass was solid heterogeneous, greyish white to tan in color with multiple foci of necrosis and cystic spaces.", + "The capsule of the tumor mass was intact grossly.", + "The uterine cavity showed thickened wall with variable cystic dilatations.", + "The other ovary and fallopian tube showed no obvious pathological abnormality.", + "Histopathological examination of the ovarian tumor mass revealed a malignant tumor composed of diffuse atypical granulosa cells.", + "The granulosa cells had spherical to oval nuclei, distinct nucleoli, and scant eosinophilic cytoplasm.", + "The granulosa cells were arranged in different patterns including micro follicles, small nests, acinar formation, and alveolar-like.", + "Regions of the tumor exhibited Sertoli-pattern (Luteinization).", + "Other regions showed sarcomatous spindle cells arranged in tight fascicles.", + "The cells were separated by connective tissue septa along with areas of hemorrhage and necrosis.", + "Mitotic count showed 2–3 mitosis / 10 hpF.", + "The fibroconnective tissue capsule revealed evidence of vascular invasion.", + "The endometrium examination revealed thickened endometrial lining with elongated glands and prominent stroma.", + "There was dilatation of glands with formation of variable sized cysts.", + "No cytological atypia was seen.", + "No evidence of complexity or tumor deposits or invasion was found.", + "The contralateral ovary and fallopian tube showed normal histological findings.", + "Based on histological findings, the GCT of the ovary with evidence of vascular invasion associated with CEH was made.", + "The contralateral ovary and fallopian tube were free.", + "The surgical intervention resulted in the complete resolution of clinical signs.", + "Six months following surgery the cat was brought to the clinic again with complaints of weakness, cachexia, ascites, off food, and lethargy.", + "A palpable abdominal mass was present.", + "Sings of pain were determined on palpation of the right abdominal region.", + "Ultrasonography examination was performed.", + "A clear mass at the mesogastric region attached to the right kidney was determined.", + "The mass was suspected as a sequela of past tumor metastasis.", + "Surgery was not performed due to poor prognosis.", + "The cat had paralysis in hind limbs and massive weight loss after one week.", + "The cat eventually died.", + "The owner of the cat rejected the euthanized decision.", + "Postmortem examination was not performed." + ], + "summary": "The cat was brought for a routine diagnostic examination for pregnancy at Albaittar clinic in Tripoli, Libya with a history of 1 month mating before it was brought to the clinic for investigation of progressive behavioral changes. The cat external examination showed noticeable enlargement in the abdomen that was potentially suspected of pregnancy; however, the abdominal ultrasonography showed a great mass located on the right ovary. A therapeutic ovariohysterectomy was performed. The cat's clinical signs resolved, 6 months later it was diagnosed with a mass on the right kidney suspected as metastasis and one week later the cat died.", + "summary_subclaims": [ + "The cat was brought for a routine diagnostic examination for pregnancy at Albaittar clinic in Tripoli, Libya.", + "The cat had a history of 1 month mating before being brought to the clinic.", + "The cat was brought to the clinic for investigation of progressive behavioral changes.", + "The cat's external examination showed noticeable enlargement in the abdomen.", + "The abdominal enlargement was potentially suspected of pregnancy.", + "Abdominal ultrasonography showed a great mass located on the right ovary.", + "A therapeutic ovariohysterectomy was performed.", + "The cat's clinical signs resolved.", + "Six months later, the cat was diagnosed with a mass on the right kidney.", + "The mass on the right kidney was suspected as metastasis.", + "One week after the kidney mass diagnosis, the cat died." + ] + }, + { + "id": "multiclinsum_test_344_en.txt", + "fulltext": "66-years-old male.\nA sudden onset of the right hemiplegia and dysarthria.\nNothing significant.\nSmoked 30 cigarettes/day for 45 years.\nAt 7:30 a.m. while driving, the patient suddenly experienced right hemiplegia and dysarthria and was rushed to our hospital.\nRight facial paralysis, dysarthria, right upper extremity paralysis, right upper and lower extremity paresthesia, and National Institutes of Health Stroke Scale (NIHSS) score 6/42.\nMagnetic resonance imaging (MRI) diffusion-weighted imaging (DWI) showed slightly high signal areas in the left putamen, corona radiata, and part of the middle cerebral artery region. Magnetic resonance angiography (MRA) showed an occlusion of the left middle cerebral artery [ and ]. The T2-weighted images showed no obvious thrombi in the occluded area.\nThe patient was admitted to the hospital at 8:25 a.m. Based on the MRI findings, we determined that there was a mismatch between the perfusion area of the left middle cerebral artery and the high signal DWI lesion. An intravenous alteplase therapy was deemed appropriate without any cautionary or contraindicated items as per the guidelines. Alteplase was administered at 9:27 a.m. following the management of hypotension with nicardipine. The primary strategy was to pursue an endovascular recanalization.\nA 9 Fr sheath was placed in the right femoral artery, and a 9 Fr OPTIMO (Tokai Medical Products, Aichi, Japan) was guided into the left internal carotid artery. Internal carotid arteriography revealed that the left middle cerebral artery was distally occluded . In the delayed phase, an anastomosis of the cerebral pia mater provided the collateral blood flow from the anterior to the middle cerebral arteries . The rebar (Medtronic, Minneapolis, MN, USA) was guided distal to the occlusion with a CHIKAI 14 200 cm (Asahi Intec, Aichi, Japan) to secure the distal vessel, and a Trevo XP ProVue Retriever 4.0 × 30 mm (Stryker, Kalamazoo, MI, USA) was deployed. The post deployment imaging showed an immediate flow restoration but poor stent dilation in the occluded area, suggestive of arterial stenosis .\nThe proximal and distal diameters of the stenosis were 2.6 mm and 2.1 mm, respectively . After retrieving the Trevo, a 1-min amount of thrombus was retrieved. Although reperfusion was achieved, a significant degree of stenosis persisted . A diagnosis of ICAD was established, and an angioplasty using a balloon catheter was proposed.\nCrushed aspirin and clopidogrel (300 mg each) were administered orally. A 6 Fr Cerulean catheter DD6 113 cm (Medikit, Tokyo, Japan) was guided to the pyramidal segment of the internal carotid artery as a distal access catheter. Subsequently, a Gateway 2.0 × 12 mm monorail (Stryker, Kalamazoo, Michigan, USA) was placed at the stenosis region using a CHIKAI. A gradual dilatation and retraction were performed under nominal pressure . Subsequent imaging revealed a temporary recanalization ; however, restenosis was observed after 7 min .\nThe strategy was to use a coronary perfusion balloon for prolonged angioplasty while maintaining the peripheral perfusion. Ryusei 2.5 × 20 mm monorail (Kaneka Medix, Osaka, Japan) was navigated toward the stenotic lesion. After dilating to 2 atm, the wire was drawn anterior to the proximal perfusion hole, and the perfusion lumen was subsequently unsealed .\nThe angiography performed in this state showed that peripheral perfusion was achieved using balloon dilation [ and ]. The patient was maintained in this state for 15 min, during which intermittent angiography was performed to monitor the patency of the perfusion lumen. Ozagrel sodium 80 mg was administered intravenously. The Ryusei was then deflated and adequate vascular dilation was observed . After an additional waiting period of 20 min, we confirmed the absence of restenosis and concluded the procedure.\nHeparin was administered while monitoring activated clotting time (ACT) during the procedure, with a minimum ACT value of 200. The total dose was 6,000 units.\nThe patient’s symptoms resolved to an NIHSS score of 0 on the day after the procedure. Postoperative echocardiography and electrocardiography revealed no evidence of cardiogenic cerebral embolism. Based on the intraoperative findings, the patient was diagnosed with ICAD. Postoperatively, aspirin 100 mg and clopidogrel 75 mg prescriptions were continued, and cilostazol 200 mg and atorvastatin 10 mg were added. Postoperative MRI showed a clearly defined high signal DWI without significant enlargement of the infarcted area and although a mild stenosis remained, the MRA also showed a satisfactory peripheral perfusion .\nThe patient was discharged without a neurological deficit on the 7th day.\nClopidogrel medication was discontinued at discharge. Three months later, the MRA indicated an improvement in the stenosis , and the patient was prescribed antithrombotic therapy with cilostazol as a single agent. No specific events were observed for more than 1 year after the procedure.\nAn application for an unapproved new medical device was submitted to the hospital’s committee for the evaluation of highly difficult new medical technology, and approval was obtained. Furthermore, during patient consultations regarding surgical procedures, we explicitly conveyed that we may employ nonconforming medical devices if adequate substitutions proved arduous and secured informed consent accordingly.", + "fulltext_subclaims": [ + "The patient is a 66-years-old male.", + "The patient had a sudden onset of right hemiplegia and dysarthria.", + "The patient smoked 30 cigarettes/day for 45 years.", + "The patient experienced right hemiplegia and dysarthria at 7:30 a.m. while driving.", + "Right facial paralysis was observed.", + "Right upper extremity paralysis was observed.", + "Right upper and lower extremity paresthesia was observed.", + "The NIHSS score was 6/42.", + "MRI diffusion-weighted imaging showed slightly high signal areas in the left putamen, corona radiata, and part of the middle cerebral artery region.", + "MRA showed an occlusion of the left middle cerebral artery.", + "The T2-weighted images showed no obvious thrombi in the occluded area.", + "The patient was admitted to the hospital at 8:25 a.m.", + "An intravenous alteplase therapy was deemed appropriate.", + "Alteplase was administered at 9:27 a.m.", + "The primary strategy was to pursue an endovascular recanalization.", + "A 9 Fr sheath was placed in the right femoral artery.", + "An OPTIMO was guided into the left internal carotid artery.", + "Internal carotid arteriography revealed that the left middle cerebral artery was distally occluded.", + "In the delayed phase, an anastomosis of the cerebral pia mater provided the collateral blood flow from the anterior to the middle cerebral arteries.", + "A Trevo XP ProVue Retriever 4.0 × 30 mm was deployed.", + "The post deployment imaging showed an immediate flow restoration.", + "The post deployment imaging showed poor stent dilation in the occluded area.", + "The proximal and distal diameters of the stenosis were 2.6 mm and 2.1 mm, respectively.", + "A 1-min amount of thrombus was retrieved.", + "A diagnosis of ICAD was established.", + "An angioplasty using a balloon catheter was proposed.", + "Crushed aspirin and clopidogrel (300 mg each) were administered orally.", + "A Gateway 2.0 × 12 mm monorail was placed at the stenosis region.", + "A gradual dilatation and retraction were performed under nominal pressure.", + "Subsequent imaging revealed a temporary recanalization.", + "Restenosis was observed after 7 min.", + "The strategy was to use a coronary perfusion balloon for prolonged angioplasty.", + "A Ryusei 2.5 × 20 mm monorail was navigated toward the stenotic lesion.", + "After dilating to 2 atm, the wire was drawn anterior to the proximal perfusion hole.", + "The perfusion lumen was subsequently unsealed.", + "The angiography performed in this state showed that peripheral perfusion was achieved using balloon dilation.", + "The patient was maintained in this state for 15 min.", + "Ozagrel sodium 80 mg was administered intravenously.", + "The Ryusei was then deflated and adequate vascular dilation was observed.", + "After an additional waiting period of 20 min, we confirmed the absence of restenosis.", + "Heparin was administered while monitoring activated clotting time (ACT) during the procedure.", + "The minimum ACT value was 200.", + "The total heparin dose was 6,000 units.", + "The patient’s symptoms resolved to an NIHSS score of 0 on the day after the procedure.", + "Postoperative echocardiography and electrocardiography revealed no evidence of cardiogenic cerebral embolism.", + "Based on the intraoperative findings, the patient was diagnosed with ICAD.", + "Postoperatively, aspirin 100 mg and clopidogrel 75 mg prescriptions were continued.", + "Cilostazol 200 mg and atorvastatin 10 mg were added.", + "Postoperative MRI showed a clearly defined high signal DWI without significant enlargement of the infarcted area.", + "Mild stenosis remained.", + "The MRA also showed a satisfactory peripheral perfusion.", + "The patient was discharged without a neurological deficit on the 7th day.", + "Clopidogrel medication was discontinued at discharge.", + "Three months later, the MRA indicated an improvement in the stenosis.", + "The patient was prescribed antithrombotic therapy with cilostazol as a single agent.", + "No specific events were observed for more than 1 year after the procedure.", + "An application for an unapproved new medical device was submitted to the hospital’s committee for the evaluation of highly difficult new medical technology.", + "Approval was obtained.", + "During patient consultations regarding surgical procedures, we explicitly conveyed that we may employ nonconforming medical devices if adequate substitutions proved arduous.", + "Informed consent was secured accordingly." + ], + "summary": "A 66-year-old male patient presented with an acute onset of right hemiplegia and dysarthria. Magnetic resonance imaging revealed an occlusion of the left middle cerebral artery, and alteplase was administered, followed by a mechanical thrombectomy and intracranial balloon catheter angioplasty. Due to restenosis, a coronary perfusion balloon catheter was used for a 15-minute angioplasty procedure while maintaining the perfusion. This treatment approach led to the recanalization of the artery and favorable clinical outcomes.", + "summary_subclaims": [ + "The patient is a 66-year-old male.", + "The patient presented with an acute onset of right hemiplegia.", + "The patient presented with dysarthria.", + "Magnetic resonance imaging revealed an occlusion of the left middle cerebral artery.", + "Alteplase was administered.", + "A mechanical thrombectomy was performed.", + "An intracranial balloon catheter angioplasty was performed.", + "Due to restenosis, a coronary perfusion balloon catheter was used.", + "A 15-minute angioplasty procedure was performed.", + "Perfusion was maintained during the procedure.", + "The treatment approach led to the recanalization of the artery.", + "The treatment approach led to favorable clinical outcomes." + ] + }, + { + "id": "multiclinsum_test_2560_en.txt", + "fulltext": "A 72-year-old Bahraini female known to have type 2 diabetes mellitus, resistant systemic hypertension, hyperlipidaemia, and peripheral artery disease (PAD) with a history of stenting distal abdominal aorta (12 mm × 40 mm S.M.A.R.T control self-expanding stent) and right common iliac artery (7 mm × 17 mm Express LD) in 2014 was referred to our cardiac centre for evaluation of repeated episodes of FPE.\nOn arrival, she was in mild dyspnoea and oliguric. Her blood pressure was 182/105 mmHg, and her heart rate was 109 b.p.m. Physical examination has revealed bilateral basal crackle with no audible cardiac murmur and periumbilical, high-pitched bruits. Her electrocardiogram showed QRS voltage criteria for left ventricular hypertrophy, which was confirmed with a transthoracic echocardiogram that revealed concentric left ventricular hypertrophy with Grade II diastolic dysfunction and normal left ventricular size and systolic function with no regional wall motion abnormality. Baseline Creatinine was 225 µmol/L (reference range 44–88 µmol/L) and hence we performed the coronary angiogram with minimal contrast (18 cc only) to rule out underlying coronary artery disease in view of multiple risk factors and troponinaemia, which showed coronary calcifications but no flow-limiting disease in the epicardial coronaries. Since the patient had resistant systemic hypertension with abdominal bruits, non-selective renal angiography was conducted and showed bilateral heavily calcified high-grade ostioproximal RAS. While we were sorting out a strategy for ad hoc intervention for the tight renal arteries she desaturated, her blood pressure raised to 240/130 mmHg, her heart rate increased to 130 b.p.m., and her respiration rate was 26/min with diffuse bilateral fine crackles. Considering acute florid pulmonary oedema and being anuric despite large dose of diuretics, we aborted the procedure and timely inserted the right internal jugular dialysis line and transferred her to the cardiac care unit for urgent haemodialysis.\nThe next day, after full stabilization, we brought her back to the Cath lab for renal angioplasty. We decided for the left transradial approach for two reasons: the left radial artery has a shorter distance to the renal arteries than the right radial artery and the angles of the renal arteries off the aorta favour a radial approach than a retrograde femoral access.\nUnder local anaesthesia, the left radial artery access was achieved with a 7-Fr sheath. We managed to navigate a 90 cm sheath across an unexpected left subclavian stenosis with balloon dilatation and slide it subsequently across a tortuous descending aorta using NaviCross microcatheter and Terumo Glidewire Advantage, which was exchanged to Hi-Torque supracore guidewire thereafter to land the sheath into the abdominal aorta.\nA 7-Fr multipurpose guide catheter engaged the right renal artery, and a selective renal angiogram confirmed the presence of critical calcified stenosis at the proximal part of the right renal artery .\nThe lesion crossed with Hi-Torque BMW 0.014 × 300 cm guidewire. Intravascular ultrasound pullback showed a very high superficial and deep calcium burden in the proximal segment of the right renal artery with a 5.2 cm reference vessel diameter . Considering severe calcifications, we decided to proceed with shockwave lithotripsy using a 4.0 mm × 12 mm, 138 cm shockwave C2 IVL balloon with a total of 80 pulses. Fair expansion of the 4.0 mm IVL balloon at 6 atmospheres was achieved . Now, without further balloon dilation, a 5.0 mm × 18 mm Resolute Onyx stent was deployed at 14 atmospheres with a good final angiographic result .\nThe same procedure was applied for the left renal artery after confirmation of tight osteoproximal lesion with selective injection . This time, the IVUS study showed a larger vessel diameter of 7.1 cm with severe semi-circumferential calcium arc that we overcame successfully with 6.0 mm × 60 mm, 110 cm shockwave M5 IVL balloon (10 rounds each of 30 pulses) at 6 atm . Once the lithotripsy treatment is completed, a 7.0 mm × 17 mm Express SD Renal stent was deployed at 10 bar. Final angiography demonstrated an excellent position of the stent and confirmed patency of the left renal artery . The patient tolerated the procedure well and was transferred to the cardiology ward for further monitoring. A few hours later, we noticed a dramatic improvement of blood pressure measurements and urine output. She required one more haemodialysis session to enhance renal recovery and minimize the risk of contrast induced-nephropathy and was successfully discharged to home 48 h post-procedure.\nIn the 2-week of follow-up, she was asymptomatic, serum creatinine almost normalized (96 µmol/L, reference range 44–88 µmol/L) with adequate blood pressure control. Three months after discharge, renal function recovered completely and return to normal (Creatinine 81 µmol/L, reference range 44–88 µmol/L) with good blood pressure control on amlodipine 10 mg o.d. only.\nIn our institution, there are no standards for routine duplex or imaging follow-up after renal angioplasty unless mandated clinically.", + "fulltext_subclaims": [ + "The patient is a 72-year-old Bahraini female.", + "She has type 2 diabetes mellitus.", + "She has resistant systemic hypertension.", + "She has hyperlipidaemia.", + "She has peripheral artery disease.", + "She had stenting of the distal abdominal aorta in 2014.", + "She had stenting of the right common iliac artery in 2014.", + "She was referred for evaluation of repeated episodes of FPE.", + "On arrival, she was in mild dyspnoea.", + "On arrival, she was oliguric.", + "Her blood pressure was 182/105 mmHg.", + "Her heart rate was 109 b.p.m.", + "Physical examination revealed bilateral basal crackles.", + "Her electrocardiogram showed QRS voltage criteria for left ventricular hypertrophy.", + "A transthoracic echocardiogram revealed concentric left ventricular hypertrophy.", + "The echocardiogram showed Grade II diastolic dysfunction.", + "Baseline creatinine was 225 µmol/L.", + "A coronary angiogram was performed with minimal contrast.", + "The coronary angiogram showed coronary calcifications.", + "The coronary angiogram showed no flow-limiting disease in the epicardial coronaries.", + "Non-selective renal angiography showed bilateral heavily calcified high-grade ostioproximal RAS.", + "The patient desaturated during the procedure.", + "Her blood pressure increased to 240/130 mmHg.", + "Her heart rate increased to 130 b.p.m.", + "She had diffuse bilateral fine crackles.", + "The procedure was aborted.", + "A right internal jugular dialysis line was inserted.", + "She was transferred to the cardiac care unit for urgent haemodialysis.", + "The next day, she was brought back to the Cath lab for renal angioplasty.", + "A left radial artery access was achieved with a 7-Fr sheath.", + "A 90 cm sheath was navigated across an unexpected left subclavian stenosis.", + "The sheath was slid across a tortuous descending aorta.", + "A 7-Fr multipurpose guide catheter engaged the right renal artery.", + "A selective renal angiogram confirmed critical calcified stenosis at the proximal part of the right renal artery.", + "The lesion was crossed with a Hi-Torque BMW 0.014 × 300 cm guidewire.", + "Intravascular ultrasound showed a 5.2 cm reference vessel diameter.", + "Shockwave lithotripsy was performed using a 4.0 mm × 12 mm shockwave C2 IVL balloon.", + "A 5.0 mm × 18 mm Resolute Onyx stent was deployed at 14 atmospheres.", + "The same procedure was applied for the left renal artery.", + "An IVUS study showed a 7.1 cm vessel diameter.", + "A 6.0 mm × 60 mm shockwave M5 IVL balloon was used.", + "A 7.0 mm × 17 mm Express SD Renal stent was deployed at 10 bar.", + "Final angiography demonstrated an excellent position of the stent.", + "The patient tolerated the procedure well.", + "She was transferred to the cardiology ward.", + "She required one more haemodialysis session.", + "She was discharged 48 hours post-procedure.", + "In the 2-week follow-up, she was asymptomatic.", + "Serum creatinine almost normalized to 96 µmol/L.", + "Three months after discharge, renal function recovered completely.", + "Creatinine was 81 µmol/L.", + "She was on amlodipine 10 mg o.d. only.", + "There are no standards for routine duplex or imaging follow-up after renal angioplasty unless mandated clinically." + ], + "summary": "We herein report a case of symptomatic bilateral severely calcified RAS, treated successfully with intravascular ultrasound (IVUS)-guided coronary and peripheral intravascular shockwave lithotripsy systems and stenting.", + "summary_subclaims": [ + "The patient had symptomatic bilateral severely calcified RAS.", + "The patient was treated with intravascular ultrasound (IVUS)-guided coronary and peripheral intravascular shockwave lithotripsy systems.", + "The patient was treated with stenting.", + "The treatment was successful." + ] + }, + { + "id": "multiclinsum_test_651_en.txt", + "fulltext": "The reported patient is a 15-year-old girl with βTI, who presented at the age of 3 years with pallor, decreased growth rate and decreased activity. She had severe microcytic, hypochromic anemia with hemoglobin (Hb) of 7.3 g/dL.\nPediatric hematologist workup proved the diagnosis of βTI. Her Hb electrophoresis showed; 69.9% HbA, 27.2% HbF, and 2.9% HbA2. Genetic molecular testing revealed compound heterozygosity for cd-27 (G>T) and cd-39 (C>T) mutations. Hydroxyurea at a dose of 15 mg/kg per day was started, in addition to folic acid.\nShe was then followed at the pediatric hematology unit at regular intervals to monitor her tolerance to drug therapy, with special attention to hematological toxicity. There were no significant side effects during seven years of therapy, and the patient showed good response with occasional need for blood transfusions. She underwent splenectomy during her late teens.\nAt the age of 15 years, she developed generalized bone aches, abdominal pain, persistent fever, and dyspnea, and so she was referred to our hospital.\nOn physical examination, there was severe pallor, tachypnea, tachycardia, and hepatomegaly.\nInitial complete blood picture showed a Hb level 3.9 g/dL, white blood cell count of 250 × 109/L, and platelets count of 640 × 10-9/L.\nSerum electrolytes, cerebrospinal fluid analysis, and kidney and liver function tests were normal, expect for mild elevation of total serum bilirubin, which was 1.3 mg/dL.\nSerum ferritin was 877 ng/dL. Serological studies including Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus, hepatitis C virus and hepatitis B virus were negative. Lactate dehydrogenase was 974 U/L, and serum uric acid was 5.6 mg/dL.\nHer chest X-ray was normal. Abdominal ultrasonography revealed hepatomegaly with calcular cholecystitis and bilateral diffuse renal enlargement. Echocardiography showed mitral valve prolapse with trivial mitral regurgitation.", + "fulltext_subclaims": [ + "The patient is a 15-year-old girl with βTI.", + "She presented at the age of 3 years with pallor, decreased growth rate, and decreased activity.", + "She had severe microcytic, hypochromic anemia with hemoglobin (Hb) of 7.3 g/dL.", + "Pediatric hematologist workup proved the diagnosis of βTI.", + "Her Hb electrophoresis showed 69.9% HbA, 27.2% HbF, and 2.9% HbA2.", + "Genetic molecular testing revealed compound heterozygosity for cd-27 (G>T) and cd-39 (C>T) mutations.", + "Hydroxyurea at a dose of 15 mg/kg per day was started, in addition to folic acid.", + "She was followed at the pediatric hematology unit at regular intervals to monitor her tolerance to drug therapy.", + "There were no significant side effects during seven years of therapy.", + "The patient showed good response with occasional need for blood transfusions.", + "She underwent splenectomy during her late teens.", + "At the age of 15 years, she developed generalized bone aches, abdominal pain, persistent fever, and dyspnea.", + "On physical examination, there was severe pallor, tachypnea, tachycardia, and hepatomegaly.", + "Initial complete blood picture showed a Hb level of 3.9 g/dL.", + "Initial complete blood picture showed a white blood cell count of 250 × 109/L.", + "Initial complete blood picture showed a platelets count of 640 × 10-9/L.", + "Serum electrolytes, cerebrospinal fluid analysis, and kidney and liver function tests were normal, except for mild elevation of total serum bilirubin, which was 1.3 mg/dL.", + "Serum ferritin was 877 ng/dL.", + "Serological studies including Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus, hepatitis C virus, and hepatitis B virus were negative.", + "Lactate dehydrogenase was 974 U/L.", + "Serum uric acid was 5.6 mg/dL.", + "Her chest X-ray was normal.", + "Abdominal ultrasonography revealed hepatomegaly with calculi cholecystitis and bilateral diffuse renal enlargement.", + "Echocardiography showed mitral valve prolapse with trivial mitral regurgitation." + ], + "summary": "We recently reported the first case of acute lymphoblastic leukemia (ALL) from Egypt in a child with βTM, and we herein report the first case of ALL from Egypt in a child with βTI. In this report, literature was reviewed for cases of malignancies associated with βTI and the possible factors underling the relationship between the two entities.", + "summary_subclaims": [ + "We recently reported the first case of acute lymphoblastic leukemia (ALL) from Egypt in a child with βTM.", + "We herein report the first case of ALL from Egypt in a child with βTI.", + "In this report, literature was reviewed for cases of malignancies associated with βTI.", + "In this report, literature was reviewed for the possible factors underling the relationship between malignancies and βTI." + ] + }, + { + "id": "multiclinsum_test_2459_en.txt", + "fulltext": "A 37-year-old Chinese woman was diagnosed as hormone receptor-positive and HER2-positive infiltrating duct carcinoma in her left breast.\nThe patient felt a painless lump in the left breast during a physical examination. After several examinations, she underwent breast-conserving surgery, and sentinel lymph node biopsy was resultingly found to be 1/4 positive.\nThe patient’s prior medical history was unremarkable. The patient did not demonstrate any history of drug allergies and had no history of ear, nose, and throat (ENT), migraine or other central nervous system diseases.\nThe patient gave birth at the age of 25 and breastfed her infant. She experienced regular menstrual cycles and had no family history of cancer.\nA physical examination of the patient revealed a 1.0 cm × 1.0 cm non-tender mass in the upper outer quadrant of the left breast. Her physical examination confirmed no signs of ENT diseases, central nervous system diseases or cerebral metastasis. And she had a body mass index (BMI) of 30.4.\nLaboratory examinations (routine blood analysis, liver biochemical analysis, renal function, tumor markers, etc.) were normal.\nThe patient’s lungs, bones and liver were normal. Imaging examination did not demonstrate any evidence of distant metastases. A cerebral magnetic resonance imaging scan revealed no sign of intracranial or skeletal cranial metastases or any vascular disorders .", + "fulltext_subclaims": [ + "A 37-year-old Chinese woman was diagnosed as hormone receptor-positive and HER2-positive infiltrating duct carcinoma in her left breast.", + "The patient felt a painless lump in the left breast during a physical examination.", + "She underwent breast-conserving surgery.", + "Sentinel lymph node biopsy was resultingly found to be 1/4 positive.", + "The patient’s prior medical history was unremarkable.", + "The patient did not demonstrate any history of drug allergies.", + "She had no history of ear, nose, and throat (ENT), migraine or other central nervous system diseases.", + "The patient gave birth at the age of 25 and breastfed her infant.", + "A physical examination of the patient revealed a 1.0 cm × 1.0 cm non-tender mass in the upper outer quadrant of the left breast.", + "Her physical examination confirmed no signs of ENT diseases, central nervous system diseases or cerebral metastasis.", + "She had a body mass index (BMI) of 30.4.", + "Laboratory examinations (routine blood analysis, liver biochemical analysis, renal function, tumor markers, etc.) were normal.", + "The patient’s lungs, bones and liver were normal.", + "Imaging examination did not demonstrate any evidence of distant metastases.", + "A cerebral magnetic resonance imaging scan revealed no sign of intracranial or skeletal cranial metastases or any vascular disorders." + ], + "summary": "A 37-year-old woman was diagnosed with hormone receptor-positive and human epidermal growth factor receptor 2-positive breast cancer. After surgery, she was treated with four cycles of epirubicin and cyclophosphamide; she then received docetaxel and a loading dose of trastuzumab plus pertuzumab. Less than half an hour after trastuzumab infusion, the patient complained of severe tinnitus and left-sided migraine headache. Trastuzumab monotherapy was discontinued immediately, and symptoms disappeared after 10 min. Trastuzumab was readministered, and severe tinnitus and migraine headache recurred. Trastuzumab was stopped, and severe tinnitus diminished after 10 min. Pertuzumab and docetaxel therapy was then administered, and no adverse events were observed. Subsequent infusions of trastuzumab every three weeks did not show the same symptoms.", + "summary_subclaims": [ + "The patient was diagnosed with hormone receptor-positive and human epidermal growth factor receptor 2-positive breast cancer.", + "The patient was treated with four cycles of epirubicin and cyclophosphamide.", + "The patient received docetaxel and a loading dose of trastuzumab plus pertuzumab.", + "Less than half an hour after trastuzumab infusion, the patient complained of severe tinnitus and left-sided migraine headache.", + "Trastuzumab monotherapy was discontinued immediately.", + "Symptoms disappeared after 10 min.", + "Trastuzumab was readministered.", + "Severe tinnitus and migraine headache recurred.", + "Trastuzumab was stopped.", + "Severe tinnitus diminished after 10 min.", + "Pertuzumab and docetaxel therapy was then administered.", + "No adverse events were observed.", + "Subsequent infusions of trastuzumab every three weeks did not show the same symptoms." + ] + }, + { + "id": "multiclinsum_test_1221_en.txt", + "fulltext": "A 36-year-old Caucasian woman, gravida 3, para 2, presented to our antenatal outpatient clinic in the 10th week of gestation complaining of uterine prolapse and amenorrhea. Five years earlier, at the age of 31 years, she had her first spontaneous vaginal delivery, after 39 weeks of clinically unremarkable gestation and after a seven-hour labor. A living male baby weighing 2950 g, with Apgar scores of 10/10, was delivered. After that, a total uterine prolapse (POP-Q IV) was observed and, therefore, a pelvic reconstruction operation was scheduled. However, she missed the appointment and she was lost to follow-up.\nFour years later, at the age of 35 years, the patient had her first pregnancy in a prolapsed uterus and the delivery was performed by an elective caesarean section after 38 weeks of gestation. During this second pregnancy follow-up she experienced symptoms of heaviness, but no pelvic pain or urinary incontinence. Pelvic examination showed that the uterus persisted in the pelvis because of increased volume. The cervical os was closed, while the entire cervix was lying outside the vulva during the first three months and after week 18 it appeared completely inside. When the cervix was outside the vulva, it appeared enlarged and edematous with marked ectropion but it was not ulcerated. A live male baby weighing 3150 g, with Apgar scores of 10/10, was delivered with elective caesarian section. After that, a total uterine prolapse persisted but she refused any procedure for pelvic reconstruction; neither was a vaginal pessary used.\nOne year later, at the age of 36 years, she presented again in our clinic with a 10-week pregnancy in a prolapsed uterus. A vaginal pessary was applied to keep the uterus inside the pelvis after manual reposition. The pessary was removed at the 24th week. The gravid uterus persisted in the abdominal cavity because it was increased in volume . She did not show any symptoms of heaviness or urinary incontinence. The cervix was lying at the os of the vulva (POP-Q II) without signs of dessication or ulceration. It was enlarged and edematous but showed no evidence of cervical incompetence.\nSerial transabdominal ultrasonograpic examinations showed a normally developing fetus in longitudinal position in the uterine cavity. Elective caesarean section was performed at the 38th week. A living, healthy female baby weighing 3030 g, with Apgar scores of 10/10, was delivered.\nThe postnatal period was uneventful and she was discharged home four days later in good health. Normal postpartum uterine involution was observed. After that, a total uterine prolapse (POP-Q IV) was still observed .\nShe is scheduled for follow-up examination and pelvic reconstruction surgery.", + "fulltext_subclaims": [ + "The patient is a 36-year-old Caucasian woman.", + "She is gravida 3, para 2.", + "She presented in the 10th week of gestation.", + "She complained of uterine prolapse.", + "She complained of amenorrhea.", + "Five years earlier, at the age of 31 years, she had her first spontaneous vaginal delivery.", + "The first delivery was after 39 weeks of clinically unremarkable gestation.", + "The first delivery was after a seven-hour labor.", + "A living male baby weighing 2950 g was delivered.", + "The Apgar scores were 10/10.", + "A total uterine prolapse (POP-Q IV) was observed.", + "A pelvic reconstruction operation was scheduled.", + "She missed the appointment.", + "She was lost to follow-up.", + "Four years later, at the age of 35 years, the patient had her first pregnancy in a prolapsed uterus.", + "The delivery was performed by an elective caesarean section.", + "The delivery was after 38 weeks of gestation.", + "During the second pregnancy follow-up, she experienced symptoms of heaviness.", + "She did not experience pelvic pain.", + "She did not experience urinary incontinence.", + "Pelvic examination showed that the uterus persisted in the pelvis because of increased volume.", + "The cervical os was closed.", + "The entire cervix was lying outside the vulva during the first three months.", + "After week 18, the cervix appeared completely inside.", + "When the cervix was outside the vulva, it appeared enlarged and edematous with marked ectropion.", + "The cervix was not ulcerated.", + "A live male baby weighing 3150 g was delivered.", + "The Apgar scores were 10/10.", + "After the second delivery, a total uterine prolapse persisted.", + "She refused any procedure for pelvic reconstruction.", + "A vaginal pessary was not used.", + "One year later, at the age of 36 years, she presented with a 10-week pregnancy in a prolapsed uterus.", + "A vaginal pessary was applied after manual reposition.", + "The pessary was removed at the 24th week.", + "The gravid uterus persisted in the abdominal cavity because it was increased in volume.", + "She did not show symptoms of heaviness.", + "She did not show urinary incontinence.", + "The cervix was lying at the os of the vulva (POP-Q II).", + "The cervix was not desiccated.", + "The cervix was not ulcerated.", + "The cervix was enlarged and edematous.", + "There was no evidence of cervical incompetence.", + "Serial transabdominal ultrasonographic examinations showed a normally developing fetus.", + "The fetus was in longitudinal position in the uterine cavity.", + "Elective caesarean section was performed at the 38th week.", + "A living, healthy female baby weighing 3030 g was delivered.", + "The Apgar scores were 10/10.", + "The postnatal period was uneventful.", + "She was discharged home four days later in good health.", + "Normal postpartum uterine involution was observed.", + "After delivery, a total uterine prolapse (POP-Q IV) was still observed.", + "She is scheduled for follow-up examination.", + "She is scheduled for pelvic reconstruction surgery." + ], + "summary": "A 36-year-old Caucasian woman with a history of uterine prolapse presented with pregnancy. A vaginal pessary was applied to keep her uterus inside the pelvis after manual reposition. The pessary was removed at the 24th week. The gravid uterus persisted in the abdominal cavity because of its increased volume.", + "summary_subclaims": [ + "The patient is a 36-year-old Caucasian woman.", + "The patient has a history of uterine prolapse.", + "The patient presented with pregnancy.", + "A vaginal pessary was applied to keep her uterus inside the pelvis.", + "The pessary was removed at the 24th week.", + "The gravid uterus persisted in the abdominal cavity.", + "The gravid uterus persisted in the abdominal cavity because of its increased volume." + ] + }, + { + "id": "multiclinsum_test_2001_en.txt", + "fulltext": "A 26-year-old Caucasian woman, gravida 2, para 1, with a spontaneous normal vaginal delivery 2 years ago was referred to our institution at 20.3 weeks of gestation after a sonographic finding of a sacrococcygeal mass of 26 × 24 mm in a male fetus.\nThe patient had no family history of birth defects or genetic disorders. She did not have any medical or surgical history, and she had no alcohol or smoking habit. She had no relationship with the father of her fetus and received no drug therapy while pregnant.\nShe had a normal gestational course with low risk of aneuploidies in the first-trimester screening and a normal first trimester scan at 13 weeks. Her sonographic examination revealed a single intrauterine pregnancy with an estimated gestational age of 20 weeks. The study revealed an exophytic, mixed echogenic mass arising from the sacrococcygeal region with high vascularization seen on Doppler flow . The examination showed adequate amniotic fluid, and no other abnormalities were detected.\nMagnetic resonance imaging was performed, which confirmed the diagnosis. There was no evidence of possible invasion of the fetal pelvis or abdomen. The spine appeared intact. The lower extremities, fetal kidneys, and bladder appeared normal. On the basis of these findings, a diagnosis of external variety, type I in the Altman classification, was confirmed .\nAmniocentesis guided by ultrasound scanning was done with normal karyotype and microarray results. The result of a fetal echocardiographic scan was normal.\nThe patient was scheduled for follow-up by ultrasound weekly . These scans showed an increase in the size of the mass up to 190 × 150 mm with high Doppler flow and severe polyhydramnios (amniotic fluid index 37) . The patient developed gestational diabetes, which required insulin treatment.\nAt 33.6 weeks of gestation, the patient was admitted to the obstetric ward for preterm labor. Her vital signs were normal (body temperature 36 °C, pulse rate 90 beats/minute, and blood pressure 135/82 mmHg), as was her physical examination. Treatment with a corticosteroid (12 mg intramuscularly, twice) and atosiban was started. The tocolysis was effective, and an elective cesarean section was scheduled at 35 weeks of gestation in conjunction with the neonatal service and the pediatric surgeon. However, 1 day before the scheduled cesarean section, the patient had premature rupture of membranes. Fetal heart rate monitoring revealed recurrent late decelerations at that moment, and an emergency lower segment cesarean section was performed.\nA male infant was born at 35.1 weeks with an SCT of 200 mm. The combined weight of the baby and teratoma was 4030 g . His Apgar score was 9-10-10.\nExcision of the teratoma was performed at 36 hours of life, after embolization of the middle sacral artery. Surgery was done without incident, with an operative time of 3 hours. The reconstruction was done without any excess skin . Pathological findings revealed an immature teratoma and no evidence of yolk sac tumor or other malignant elements. The postoperative alpha-fetoprotein (AFP) levels decreased quickly, being 150,000 before surgery and 64,500 afterward. The neonatal AFP values were followed during the first months with values of 14,915 at the 14th day after birth, 4136 at 6 months after birth, and 1.3 at 12 months of life. Other blood test parameters (including liver function, blood cell count, and hemostasis) were normal in both mother and infant samples.\nThe baby was discharged at 25 days after birth with normal results of abdominal, cerebral, and kidney ultrasound scans. Neonatal follow-up was performed during the first 16 months, and no long-term neurological deficits have appeared.", + "fulltext_subclaims": [ + "The patient is a 26-year-old Caucasian woman.", + "She is gravida 2, para 1.", + "She had a spontaneous normal vaginal delivery 2 years ago.", + "She was referred at 20.3 weeks of gestation.", + "A sonographic finding of a sacrococcygeal mass of 26 × 24 mm was reported in a male fetus.", + "The patient had no family history of birth defects or genetic disorders.", + "She had no medical or surgical history.", + "She had no alcohol or smoking habit.", + "She had no relationship with the father of her fetus.", + "She received no drug therapy while pregnant.", + "She had a normal gestational course.", + "The first-trimester screening showed low risk of aneuploidies.", + "A normal first trimester scan was performed at 13 weeks.", + "The sonographic examination revealed a single intrauterine pregnancy.", + "The estimated gestational age was 20 weeks.", + "An exophytic, mixed echogenic mass was seen arising from the sacrococcygeal region.", + "High vascularization was seen on Doppler flow.", + "The spine appeared intact.", + "The lower extremities, fetal kidneys, and bladder appeared normal.", + "A diagnosis of external variety, type I in the Altman classification, was confirmed.", + "Amniocentesis guided by ultrasound scanning was done.", + "The karyotype and microarray results were normal.", + "The result of a fetal echocardiographic scan was normal.", + "The patient was scheduled for weekly ultrasound follow-up.", + "The mass increased in size up to 190 × 150 mm.", + "Severe polyhydramnios was noted with an amniotic fluid index of 37.", + "The patient developed gestational diabetes.", + "Gestational diabetes required insulin treatment.", + "At 33.6 weeks of gestation, the patient was admitted for preterm labor.", + "Treatment with a corticosteroid (12 mg intramuscularly, twice) and atosiban was started.", + "The tocolysis was effective.", + "An elective cesarean section was scheduled at 35 weeks of gestation.", + "An emergency lower segment cesarean section was performed.", + "A male infant was born at 35.1 weeks.", + "The combined weight of the baby and teratoma was 4030 g.", + "The Apgar score was 9-10-10.", + "Excision of the teratoma was performed at 36 hours of life.", + "Embolization of the middle sacral artery was performed before surgery.", + "The surgery was done without incident.", + "The operative time was 3 hours.", + "The reconstruction was done without any excess skin.", + "Pathological findings revealed an immature teratoma.", + "No evidence of yolk sac tumor or other malignant elements was found.", + "The postoperative alpha-fetoprotein (AFP) levels decreased quickly.", + "The neonatal AFP values were followed during the first months.", + "The baby was discharged at 25 days after birth.", + "Neonatal follow-up was performed during the first 16 months.", + "No long-term neurological deficits have appeared." + ], + "summary": "A 26-year-old Caucasian woman at 20.3 weeks of gestation with a normal gestational course and no relevant medical or surgical history was referred to our institution with a sacrococcygeal mass diagnosis. Magnetic resonance imaging confirmed the diagnosis of sacrococcygeal teratoma type I according to the Altman classification. Follow-up with ultrasound showed an increase in the size of the mass up to 190 × 150 mm, high Doppler flow, and severe polyhydramnios. At 35.1 weeks of gestation, the patient had premature rupture of membranes, and an emergency cesarean section was performed due to recurrent late decelerations detected by fetal heart rate monitoring. Afterward, surgery was performed successfully at 36 hours of life. Posterior controls revealed normal and healthy child growth.", + "summary_subclaims": [ + "The patient is a 26-year-old Caucasian woman.", + "She was at 20.3 weeks of gestation.", + "She had a normal gestational course.", + "She had no relevant medical or surgical history.", + "She was referred to the institution with a sacrococcygeal mass diagnosis.", + "Magnetic resonance imaging confirmed the diagnosis of sacrococcygeal teratoma type I according to the Altman classification.", + "Follow-up with ultrasound showed an increase in the size of the mass up to 190 × 150 mm.", + "The ultrasound showed high Doppler flow.", + "The ultrasound showed severe polyhydramnios.", + "At 35.1 weeks of gestation, the patient had premature rupture of membranes.", + "An emergency cesarean section was performed due to recurrent late decelerations detected by fetal heart rate monitoring.", + "Surgery was performed successfully at 36 hours of life.", + "Posterior controls revealed normal and healthy child growth." + ] + }, + { + "id": "multiclinsum_test_2288_en.txt", + "fulltext": "A 74-year-old woman underwent a revision hip surgery for the treatment of a recurrent dislocation of a cemented total hip arthroplasty (eight dislocations), by malposition of the acetabular component .\nThe all-polyethylene acetabular liner was perforated with a 4.5 mm drill, and two cork-screws were firmly screwed in the rim as far as possible, in order to extrude the liner from the cement mantle, and to create also fissures into the cement . Manual torsional shear forces were carried out, which led to a total disruption of the polyethylene liner at the polyethylene-cement interface. Adequate manual torsional shear forces were carried out, which led to the disruption of the polyethylene liner at the cement-polyethylene interface, with no technical difficulties. The polyethylene cup was removed with ease. Using cement–splitting osteotomes, the cement mantle was removed in a piecemeal fashion and the cemented plugs were carefully curetted out. A roof reinforcement ring and a cemented cup of UHMW polyethylene were implanted using the standard technique. The metallic femoral head was changed and the femoral cemented stem was retained. No complications were reported in the perioperative course or during the hospitalization period. At 2 month postoperatively the patient was clinically able to walk without external support.", + "fulltext_subclaims": [ + "The patient was a 74-year-old woman.", + "She underwent revision hip surgery.", + "The surgery was for the treatment of a recurrent dislocation of a cemented total hip arthroplasty.", + "There were eight dislocations.", + "The cause was malposition of the acetabular component.", + "The all-polyethylene acetabular liner was perforated with a 4.5 mm drill.", + "Two cork-screws were firmly screwed in the rim as far as possible.", + "The cork-screws were used to extrude the liner from the cement mantle.", + "The cork-screws were used to create fissures into the cement.", + "Manual torsional shear forces were carried out.", + "Manual torsional shear forces led to a total disruption of the polyethylene liner at the polyethylene-cement interface.", + "Adequate manual torsional shear forces were carried out.", + "The disruption occurred at the cement-polyethylene interface.", + "There were no technical difficulties.", + "The polyethylene cup was removed with ease.", + "Cement–splitting osteotomes were used.", + "The cement mantle was removed in a piecemeal fashion.", + "The cemented plugs were carefully curetted out.", + "A roof reinforcement ring was implanted.", + "A cemented cup of UHMW polyethylene was implanted.", + "The standard technique was used.", + "The metallic femoral head was changed.", + "The femoral cemented stem was retained.", + "No complications were reported in the perioperative course.", + "No complications were reported during the hospitalization period.", + "At 2 months postoperatively, the patient was clinically able to walk without external support." + ], + "summary": "We report a technique using 2 cork-screws for removal a stable cemented acetabular component for the treatment of a recurrent dislocation of a cemented total hip arthroplasty, due to acetabular malposition.", + "summary_subclaims": [ + "A technique using 2 cork-screws for removal of a stable cemented acetabular component is reported.", + "The technique is for the treatment of a recurrent dislocation of a cemented total hip arthroplasty.", + "The recurrent dislocation is due to acetabular malposition." + ] + }, + { + "id": "multiclinsum_test_1482_en.txt", + "fulltext": "Our patient was a 48-year-old woman with a history of two previous cervical surgeries, the first one in 1987 and the second in 2003, with placement of titanium plates and screws at C4-C5 and C5-C6. She was seen at the clinic in 2005 with a 2-month history of fatigue, chills, headache, nausea, and asymmetric arthralgia. She also had episodes of malar rash after sun exposure and cutaneous fluctuating rash in the trunk. Physical examination revealed arthritis of the left shoulder and left ankle, livedo reticularis, and erythematous cutaneous rash in the thorax. No infection foci were detected. Laboratory studies revealed thrombocytosis 485,000 cells/mm3 (normal range 130,000–400,000 cells/mm3), elevated C-reactive protein (CRP) 75 mg/dl (normal range 0.1–1.0 mg/dl), and erythrocyte sedimentation rate (ESR) 40 mm/h (normal range 0–20 mm/h). Autoantibodies were negative, and complement levels were within normal range.\nFrom 2005 to 2007, she had no treatment, and her symptoms had a fluctuating course. In 2007, fatigue, rash, and arthralgia appeared again, and she developed edema in her hands and feet. Rheumatology started prednisone and methotrexate without improvement. Six months later, dysphagia, halitosis, and “sputum” production of purulent aspect were added to the patient’s symptoms. She consulted an ear, nose, and throat specialist, who did not find any abnormality.\nShe continued with elevated CRP, ESR, and thrombocytosis. Labeled leukocyte single-photon emission computed tomography (SPECT) suggested spondylitis in the cervical spine (C4-C6) and revealed an inflammatory process in the nasopharynx, an increase in the prevertebral space of > 2 cm, and free air in this area . An esophagogram with hydrosoluble contrast revealed a posterior pharyngoesophageal diverticulum with a fistula to C6 . The patient’s x-rays of the lateral column after the cervical spine anterior fixation in 2003 showed preserved prevertebral space, and intersomatic C4-C5 box and plate were 5 mm anterior to the vertebral bodies, pressing the esophagus .\nThe patient was taken to surgery; screws and plates were removed from C4 to C6; surgical debridement was performed; and the fistula and diverticulum were removed with cricopharyngeal myotomy and esophageal repair. Esophagography with water-soluble contrast showed no leak after surgery, but the lumen of the esophagus at C4–C6 was increased in diameter with diminished compliance. Removed plates, screws, and tissue were cultured and grew Streptococcus milleri. The patient was treated with oral amoxicillin 1 g every 8 h and probenecid for 4 months, until a gammagram was negative. Her fatigue, arthralgia, rash, and livedo reticularis as well as dysphagia disappeared. Her acute-phase reactants normalized.", + "fulltext_subclaims": [ + "The patient was a 48-year-old woman.", + "She had a history of two previous cervical surgeries, the first one in 1987 and the second in 2003.", + "Titanium plates and screws were placed at C4-C5 and C5-C6.", + "She was seen at the clinic in 2005.", + "She had a 2-month history of fatigue, chills, headache, nausea, and asymmetric arthralgia.", + "She had episodes of malar rash after sun exposure.", + "She had cutaneous fluctuating rash in the trunk.", + "Physical examination revealed arthritis of the left shoulder and left ankle.", + "Livedo reticularis was noted.", + "An erythematous cutaneous rash in the thorax was observed.", + "No infection foci were detected.", + "Thrombocytosis was 485,000 cells/mm3.", + "C-reactive protein was 75 mg/dl.", + "Erythrocyte sedimentation rate was 40 mm/h.", + "Autoantibodies were negative.", + "Complement levels were within normal range.", + "From 2005 to 2007, she had no treatment.", + "Her symptoms had a fluctuating course.", + "In 2007, fatigue, rash, and arthralgia appeared again.", + "She developed edema in her hands and feet.", + "Rheumatology started prednisone and methotrexate.", + "There was no improvement with prednisone and methotrexate.", + "Six months later, dysphagia, halitosis, and sputum production of purulent aspect were added to the patient’s symptoms.", + "An ear, nose, and throat specialist did not find any abnormality.", + "Labeled leukocyte SPECT suggested spondylitis in the cervical spine (C4-C6).", + "An inflammatory process in the nasopharynx was revealed.", + "The prevertebral space was increased by > 2 cm.", + "Free air was present in the nasopharyngeal area.", + "An esophagogram with hydrosoluble contrast revealed a posterior pharyngoesophageal diverticulum with a fistula to C6.", + "X-rays of the lateral column after the cervical spine anterior fixation in 2003 showed preserved prevertebral space.", + "The intersomatic C4-C5 box and plate were 5 mm anterior to the vertebral bodies.", + "The plates and screws were pressing the esophagus.", + "Surgical removal of screws and plates from C4 to C6 was performed.", + "Surgical debridement was performed.", + "The fistula and diverticulum were removed with cricopharyngeal myotomy and esophageal repair.", + "Esophagography with water-soluble contrast showed no leak after surgery.", + "The lumen of the esophagus at C4–C6 was increased in diameter with diminished compliance.", + "Removed plates, screws, and tissue were cultured and grew Streptococcus milleri.", + "The patient was treated with oral amoxicillin 1 g every 8 h.", + "Probenecid was given for 4 months.", + "A gammagram was negative.", + "Her fatigue, arthralgia, rash, livedo reticularis, and dysphagia disappeared.", + "Her acute-phase reactants normalized." + ], + "summary": "Our patient was a 48-year-old woman with two previous cervical surgeries with fixation of C4-C5 and C5-C6, the last one in 2003. Two years after surgery, she presented with arthralgia, arthritis, chills, and fluctuating rash. In 2007, she presented with dysphagia, halitosis, and sputum production. She was diagnosed with a pharyngoesophageal diverticulum with a fistula to C6 vertebra and secondary spondylitis. She was taken for open surgery with removal of screws and plates, cricopharyngeal myotomy, and esophageal repair. Streptococcus milleri grew in tissue and osteosynthetic material. She received 4 months of amoxicillin and probenecid and had a complete recovery. Since 1991, 19 similar cases have been reported with one fatality. To our knowledge, this is the first reported case of diverticulum complicated with fistula and secondary spondylitis.", + "summary_subclaims": [ + "The patient was a 48-year-old woman.", + "She had two previous cervical surgeries with fixation of C4-C5 and C5-C6.", + "The last cervical surgery was in 2003.", + "Two years after surgery, she presented with arthralgia, arthritis, chills, and fluctuating rash.", + "In 2007, she presented with dysphagia, halitosis, and sputum production.", + "She was diagnosed with a pharyngoesophageal diverticulum with a fistula to C6 vertebra.", + "She was diagnosed with secondary spondylitis.", + "She was taken for open surgery with removal of screws and plates.", + "She had cricopharyngeal myotomy.", + "She had esophageal repair.", + "Streptococcus milleri grew in tissue.", + "Streptococcus milleri grew in osteosynthetic material.", + "She received 4 months of amoxicillin and probenecid.", + "She had a complete recovery.", + "Since 1991, 19 similar cases have been reported.", + "There was one fatality among the 19 similar cases.", + "To our knowledge, this is the first reported case of diverticulum complicated with fistula and secondary spondylitis." + ] + }, + { + "id": "multiclinsum_test_2486_en.txt", + "fulltext": "The present case involves a 65-year-old female with a medical history of hypertension and type 2 diabetes mellitus. In 2020, her ECG showed complete left bundle branch block (LBBB), and in January 2021 the patient experienced dizziness with no apparent cardiac cause. In October 2021, the patient was seen in the outpatient clinic because of dizziness and shortness of breath. ECG and Holter monitoring revealed a 2:1 AV-block, high-degree AV-block, and complete AV-block. A trans-thoracic echo showed normal cardiac function, except for the abnormal septal movement typically seen in LBBB. Subsequently, the patient was referred to our center for brady-pacing and due to the prospect of chronic RV pacing, she was accepted for CSP.\nUpon admission for CSP implantation in October 2021, the patient had complete AV-block with a ventricular escape rhythm of 33 beats per minute. The CSP implantation was successfully performed under local anesthesia with the device placement location being subcutaneous and left-sided. The right atrial lead was successfully positioned within the right atrial appendage. Consistent with the 2021 ESC pacing and CRT guidelines (Class IIa recommendation), the operator proceeded to insert an RV backup lead at the RV apex in the context of His-pacing.\nThereafter, a ventriculogram was performed to visualize the His-region for CSP lead placement (Medtronic SelectSecure Model 3830 lumen less lead, Medtronic, Inc., Minneapolis, MN). His capture could be achieved at several sites, but pacing at high output only resulted in partial correction of the LBBB. After three unsuccessful attempts to correct the LBBB completely at the His, the decision was made to proceed with conversion to the LBBA. The CSP lead was then placed in the ventricular septum until sufficient (non-selective) LBBA pacing was achieved, with satisfying sense and threshold values. During pacing, specific observations were made; a modest R’ in V1 and a stimulus to LV activation time of less than 80ms. The inter-peak time measured was 24ms (interval between peak R-wave in V6 and R’ in V1) . Achievement of more selective LV capture was hindered by the challenge of reaching deeper into the septum. Following lead implantation, a fluoroscopic image revealed the fulcrum sign, demonstrating the placement of the CSP lead tip within the RV septal wall . Finally, a cardiac resynchronization therapy pulse generator (Medtronic Solara CRT-P, Medtronic, Inc., Minneapolis, MN) with the CSP lead connected to the LV port was implanted subcutaneously. The LBBA pacing threshold at implant was 0.5 V and the pacing settings were eventually programmed to 2.5 V/0.4ms for the LBBA lead.\nThe day after the procedure, a chest X-ray confirmed the lead position and a threshold test was performed to ensure stable pacing values . Two months after implant, during the routine device checkup, it was discovered that the LBBA pacing threshold had increased slightly to 1.25 V.\nDuring the routine device follow-up at one year, it was observed that the LBBA pacing threshold had risen to 3 V, which was above the pacing output of 2.5 V. Consequently, the patient was receiving RV only pacing from the backup lead . Attempts to increase the output led to pocket stimulation, prompting a change in the pacing configuration to LVtip – RVring at 4 V/0.7ms. Subsequent follow-up two months later revealed an even higher LBBA pacing threshold. At increased pacing output, anodal capture at the lead ring was observed, and battery life expectancy decreased drastically. As a result, RV pacing was established as the default mode, and LBBA pacing was deactivated.\nSubsequently, a CMR scan (1.5T scanner, Sola, Siemens Healthineers, Erlangen, Germany) was performed to investigate the possible cause of the increasing LBBA pacing threshold. To ensure safety during the procedure, the device was programmed in the MR safe mode. The following imaging techniques were applied: cine imaging, T1 and T2 mapping, and wideband late gadolinium enhancement (LGE) imaging (to reduce cardiac implantable electronic device–induced artefacts) as presented in Fig. . The cine imaging showed a normal LVEF of 58% and normal cardiac dimensions. Proximal LV septum thickening (14 mm) was present with hypokinesia in the same area. T1 mapping demonstrated focal high T1 values in the proximal LV septum of 1263 ± 51ms (site-specific normal myocardial T1 values: 950–1050ms) indicative of myocardial fibrosis, edema or infiltration. On T2 maps, a slightly increased T2 value was present in the same area (54.6 ± 2.7ms) as compared to the site-specific normal myocardial T2 values (42–50ms), compatible with focal edema/inflammation. LGE images revealed non-ischemic patchy mid-myocardial high signal intensity in the same proximal LV septum, suggestive of focal fibrosis. Fibrosis was not limited to the insertion point of the CSP lead tip; instead, it extended in both the basal-apical and inferoseptal-inferolateral directions. The combination of findings, including basal septal thickening with mid-myocardial focal LGE and evidence of inflammation with concomitant diffuse myocardial edema is suggestive of cardiac sarcoidosis. Therefore, further lab tests and a PET-CT scan were performed. Lab results showed an increased serum angiotensin-converting enzyme (ACE), and normal soluble Interleukin2-receptor antagonist levels. PET-CT findings did not support the diagnosis of cardiac sarcoidosis (no lymphadenopathy or avid lymph nodes within the imaged region) or the presence of active myocarditis. Alternative causes for basal septal thickening with mid-wall focal LGE could be an infiltrative cardiomyopathy, systemic disease, or a hypertrophic cardiomyopathy.", + "fulltext_subclaims": [ + "The patient is a 65-year-old female.", + "The patient has a medical history of hypertension.", + "The patient has a medical history of type 2 diabetes mellitus.", + "In 2020, the patient's ECG showed complete left bundle branch block.", + "In January 2021, the patient experienced dizziness with no apparent cardiac cause.", + "In October 2021, the patient was seen in the outpatient clinic because of dizziness and shortness of breath.", + "ECG and Holter monitoring revealed a 2:1 AV-block.", + "ECG and Holter monitoring revealed high-degree AV-block.", + "ECG and Holter monitoring revealed complete AV-block.", + "A trans-thoracic echo showed normal cardiac function, except for the abnormal septal movement typically seen in LBBB.", + "The patient was referred to the center for brady-pacing.", + "The patient was accepted for CSP due to the prospect of chronic RV pacing.", + "Upon admission for CSP implantation in October 2021, the patient had complete AV-block with a ventricular escape rhythm of 33 beats per minute.", + "The CSP implantation was successfully performed under local anesthesia.", + "The device placement location was subcutaneous and left-sided.", + "The right atrial lead was successfully positioned within the right atrial appendage.", + "The operator proceeded to insert an RV backup lead at the RV apex in the context of His-pacing.", + "The CSP lead was placed in the ventricular septum until sufficient (non-selective) LBBA pacing was achieved.", + "During pacing, a modest R’ in V1 was observed.", + "The inter-peak time measured was 24ms.", + "A fluoroscopic image revealed the fulcrum sign, demonstrating the placement of the CSP lead tip within the RV septal wall.", + "A cardiac resynchronization therapy pulse generator (Medtronic Solara CRT-P) with the CSP lead connected to the LV port was implanted subcutaneously.", + "The LBBA pacing threshold at implant was 0.5 V.", + "The pacing settings were eventually programmed to 2.5 V/0.4ms for the LBBA lead.", + "Two months after implant, the LBBA pacing threshold had increased slightly to 1.25 V.", + "At one year, the LBBA pacing threshold had risen to 3 V.", + "The patient was receiving RV only pacing from the backup lead.", + "Attempts to increase the output led to pocket stimulation.", + "The pacing configuration was changed to LVtip – RVring at 4 V/0.7ms.", + "Subsequent follow-up two months later revealed an even higher LBBA pacing threshold.", + "At increased pacing output, anodal capture at the lead ring was observed.", + "Battery life expectancy decreased drastically.", + "RV pacing was established as the default mode.", + "LBBA pacing was deactivated.", + "A CMR scan was performed to investigate the possible cause of the increasing LBBA pacing threshold.", + "The device was programmed in the MR safe mode.", + "Cine imaging showed a normal LVEF of 58%.", + "Cine imaging showed normal cardiac dimensions.", + "Proximal LV septum thickening (14 mm) was present with hypokinesia in the same area.", + "T1 mapping demonstrated focal high T1 values in the proximal LV septum of 1263 ± 51ms.", + "T1 mapping values were indicative of myocardial fibrosis, edema or infiltration.", + "T2 maps showed a slightly increased T2 value in the same area of 54.6 ± 2.7ms.", + "LGE images revealed non-ischemic patchy mid-myocardial high signal intensity in the same proximal LV septum.", + "The combination of findings is suggestive of cardiac sarcoidosis.", + "Further lab tests and a PET-CT scan were performed.", + "Lab results showed an increased serum angiotensin-converting enzyme (ACE).", + "PET-CT findings did not support the diagnosis of cardiac sarcoidosis.", + "Alternative causes for basal septal thickening with mid-wall focal LGE could be an infiltrative cardiomyopathy.", + "Alternative causes for basal septal thickening with mid-wall focal LGE could be a systemic disease.", + "Alternative causes for basal septal thickening with mid-wall focal LGE could be a hypertrophic cardiomyopathy." + ], + "summary": "A 65-year-old female with total atrioventricular block was referred for brady-pacing. Due to the potential for chronic RV pacing, CSP was chosen. The CSP implantation involved subcutaneous device placement, with a CSP lead in the left bundle branch area (LBBA) and an RV backup lead. A year after successful implantation, the LBBA pacing threshold progressively increased. Subsequent efforts to correct it led to anodal capture and battery depletion. Cardiac magnetic resonance imaging (CMR) revealed mid-septal fibrosis at the area of LBBA lead placement and suggested cardiac sarcoidosis as a possible cause.", + "summary_subclaims": [ + "The patient is a 65-year-old female.", + "The patient had total atrioventricular block.", + "The patient was referred for brady-pacing.", + "CSP was chosen due to the potential for chronic RV pacing.", + "The CSP implantation involved subcutaneous device placement.", + "A CSP lead was placed in the left bundle branch area.", + "An RV backup lead was used.", + "A year after implantation, the LBBA pacing threshold progressively increased.", + "Efforts to correct the increased pacing threshold led to anodal capture.", + "Battery depletion occurred.", + "CMR revealed mid-septal fibrosis at the area of LBBA lead placement.", + "CMR suggested cardiac sarcoidosis as a possible cause." + ] + }, + { + "id": "multiclinsum_test_48_en.txt", + "fulltext": "A 63-year-old Caucasian female patient with no past medical history was diagnosed in 2014 with cutaneous melanoma on her right heel, Breslow thickness 8.5 mm, Clark level V, mitotic figures 10/mm2. Following primary diagnosis, she underwent wide local excision with sentinel lymph node dissection that was negative for residual disease. She subsequently received adjuvant high dose interferon (5 days/week for 4 weeks), according to approved guidelines at the time. Three years later, whole body computerized tomography (CT) scanning revealed a lesion of 45 mm in the lower lobe of the left lung. Patient underwent lobectomy and histology confirmed metastatic melanoma, BRAF wild type on molecular analysis. At that point, no adjuvant treatment was provided. A year later, CT restaging revealed several pulmonary nodules scattered on both lungs, enlarged lymph nodes in the left hilum and gastroesophageal area. Given melanoma relapse, the patient received pembrolizumab intravenously (iv), 200 mg flat dose every 3 weeks, without any immune-related complications except of a mild elevation of transaminases. Three months post pembrolizumab initiation, lesions and lymphadenopathy were increased in size and therefore anti-PD1 was discontinued. The patient was scheduled to receive 4 cycles of iv ipilimumab, 3 mg/kg every 3 weeks, as second-line treatment. Approximately 2 weeks after the second administration of ipilimumab, she complained of nausea, persistent diarrhea and shivering fever and was admitted to our clinic for further evaluation and management. On physical examination, fever reached 38 °C and her abdomen was distended with hyperactive bowel sounds. The white blood cell count was 6.48 × 109/L with 71.3% neutrophils; C-reactive protein (135 mg/L, normal value < 5 mg/L) and lactate dehydrogenase (379U/L, normal range: 135–215 U/L) were increased while serum albumin was low (27.5 g/L, normal range: 35–50); transaminases and cholestatic enzymes were elevated (AST: 56 U/L, ALT: 45 U/L, GGT: 307 U/L, ALP: 170 U/L) with normal bilirubin (0.74 mg/dl, normal range: 0.3–1.2 mg/dl). Thyroid-stimulating hormone was increased (17.83 mU/L, normal range: 0.27–4.5 mU/L)] giving the suspicion for immune-mediated thyroiditis with the rest of serum endocrine parameters being normal [adrenocorticotropic hormone = 35 pg/ml (normal range: 10–65 pg/ml) and cortisol = 221.9 mmol/L (normal range: 173.6–505 mmol/L)]. Approaching her as an immunocompromised case, wide-range antibiotics were empirically delivered without resolution of her symptoms. Stool cultures for bacteria, ova and parasites, Clostridium difficile toxins (A and B), as well as polymerase chain reaction (PCR) for cytomegalovirus (CMV) were all negative. Abdominal CT scan was negative for visceral metastasis showing thickening of the large bowel wall, a finding supportive of colonic inflammation. The patient underwent sigmoidoscopy that revealed mucosal edema, hyperemia and erosions of the rectum and sigmoid colon. Representative biopsies were obtained for histological evaluation.\nHistological examination revealed multiple small, non-necrotizing epithelioid granulomas within the crypts with partial or complete destruction of the crypt epithelium and derangement but not total disruption of the basement membrane, depicted in Periodic Acid-Schiff (PAS) histochemical stain. Some intracryptal granulomas were accompanied by rupture of the crypt wall and pericryptal expansion . Active inflammation was also present characterized by moderate lamina propria lymphoplasmacytic infiltrations, focal cryptitis and rare crypt abscesses. Basal plasmacytosis, intraepithelial lymphocytes or crypt architectural distortions were not apparent while neutrophils and eosinophils were scarce. Few apoptotic bodies were occasionally seen at the crypt base. Histochemical PAS and Ziehl–Neelsen stains were negative for fungi and acid-fast bacteria respectively.\nImmunohistochemistry was performed on 4 μm-thick sections using Dako Envision Flex system (Dako, Glostrup, Denmark). The following antibodies were applied: CD20 (Dako, clone L26, mouse monoclonal, 1:700 dilution, Glostrup, Denmark), CD3 (Dako, rabbit polyclonal, 1:50 dilution), CD4 (Dako, clone 4B12, mouse monoclonal, 1:50), CD8 (Dako, clone C8/144B, mouse monoclonal, 1:200 dilution) and SMA (Dako, clone 1A4, mouse monoclonal, 1:800 dilution). Based on the above immunostains, the vast majority of lymphocytes were T cells (CD3 +) predominately CD4+. SMA highlighted the attenuation of the pericryptal myofibroblasts .\nIn view of the patient’s clinical history, the lesion was reported as granulomatous colitis probably induced by ipilimumab.\nAnti-CTLA4 was discontinued and iv prednisone at a dose of 75 mg/d was initiated with immediate clinical improvement of the diarrheic syndrome. The patient was subsequently treated with chemotherapy with no reported serious adverse events till September 2019, when radiology showed new disease progression. A re-challenge with another anti-PD1 agent, namely nivolumab, was decided, and currently the patient is under immunotherapy with stable disease regarding melanoma status and without any sign of colitis recurrence.\nRunning through the literature on PubMed and using the following terms (CTLA4, PD1/PD-L1, ipilimumab, pembrolizumab, nivolumab, immune-related adverse events, granulomatous reactions, granulomatous colitis and colon granulomas), we ended up to 5 studies that described in total 14 cases with immunotherapy related colon granulomas. A flow diagram of the performed systematic review is illustrated in Fig. . In these cases, melanoma was commonly the underlying cancer treated with ICPIs, while the median time to colitis onset exceeded 30 days with one exception of ir-colitis presentation 27 days after the initiation of a combination immunotherapy.\nOf the 14 reported cases of colitis with granuloma formation, 1 was associated with PD1 inhibitor , 2 with nivolumab/ipilimumab combination , 3 with an anti-PD1 regimen without being clearly mentioned if the patients were receiving also ipilimumab , and 5 with anti-CTLA4 treatment [, ]. For the remaining 3 cases it is not clear whether patients received ipilimumab alone or in combination with melanoma peptide vaccines to enhance host’s immunization , therefore granuloma formation could be related to ipilimumab, to vaccination or both. Table summarizes the data of the studies reporting colon granulomas in patients under ICPIs.\nApart from colon, granulomatous/sarcoid-like reactions (G/SLR) have also been described in different organs of cancer patients treated with ICPIs. Table presents a synopsis of published series with 3 or more patients under immunotherapy reporting at least one case of ICPIs-associated G/SLR in organs other than GI tract [–]. Lungs, lymph nodes and skin were the main tissues with granuloma formation, while melanoma was the main underlying malignancy.", + "fulltext_subclaims": [ + "The patient is a 63-year-old Caucasian female.", + "She had no past medical history.", + "In 2014, she was diagnosed with cutaneous melanoma on her right heel.", + "The melanoma had a Breslow thickness of 8.5 mm.", + "The melanoma was at Clark level V.", + "The melanoma had mitotic figures of 10/mm2.", + "She underwent wide local excision with sentinel lymph node dissection.", + "The sentinel lymph node dissection was negative for residual disease.", + "She received adjuvant high dose interferon.", + "The interferon was administered 5 days/week for 4 weeks.", + "The interferon treatment was according to approved guidelines at the time.", + "Three years later, whole body CT scanning revealed a 45 mm lesion in the lower lobe of the left lung.", + "She underwent lobectomy.", + "Histology confirmed metastatic melanoma.", + "Molecular analysis showed BRAF wild type.", + "No adjuvant treatment was provided after the lobectomy.", + "A year later, CT restaging revealed several pulmonary nodules scattered on both lungs.", + "CT restaging showed enlarged lymph nodes in the left hilum and gastroesophageal area.", + "The patient received pembrolizumab intravenously.", + "The pembrolizumab dose was 200 mg flat dose every 3 weeks.", + "There were no immune-related complications except for a mild elevation of transaminases.", + "Three months post pembrolizumab initiation, lesions and lymphadenopathy were increased in size.", + "Anti-PD1 was discontinued.", + "The patient was scheduled to receive 4 cycles of iv ipilimumab.", + "The ipilimumab dose was 3 mg/kg every 3 weeks.", + "Approximately 2 weeks after the second administration of ipilimumab, she complained of nausea, persistent diarrhea and shivering fever.", + "She was admitted to the clinic.", + "On physical examination, fever reached 38 °C.", + "The abdomen was distended with hyperactive bowel sounds.", + "The white blood cell count was 6.48 × 109/L.", + "C-reactive protein was 135 mg/L.", + "Lactate dehydrogenase was 379 U/L.", + "Serum albumin was 27.5 g/L.", + "Transaminases and cholestatic enzymes were elevated.", + "Thyroid-stimulating hormone was 17.83 mU/L.", + "Stool cultures for bacteria, ova and parasites, Clostridium difficile toxins, and CMV PCR were all negative.", + "Abdominal CT scan showed thickening of the large bowel wall.", + "The patient underwent sigmoidoscopy.", + "Histological examination revealed multiple small, non-necrotizing epithelioid granulomas within the crypts.", + "Histochemical PAS and Ziehl–Neelsen stains were negative for fungi and acid-fast bacteria.", + "Immunohistochemistry was performed on 4 μm-thick sections.", + "The following antibodies were applied: CD20, CD3, CD4, CD8, and SMA.", + "The lesion was reported as granulomatous colitis probably induced by ipilimumab.", + "Anti-CTLA4 was discontinued.", + "Iv prednisone at a dose of 75 mg/d was initiated.", + "The patient was subsequently treated with chemotherapy.", + "Radiology showed new disease progression in September 2019.", + "A re-challenge with nivolumab was decided.", + "The patient is under immunotherapy with stable disease.", + "There are no signs of colitis recurrence.", + "A systematic review identified 5 studies describing 14 cases of immunotherapy-related colon granulomas.", + "Melanoma was commonly the underlying cancer treated with ICPIs.", + "The median time to colitis onset exceeded 30 days.", + "One case of ir-colitis presented 27 days after initiation of combination immunotherapy.", + "Of the 14 reported cases, 1 was associated with a PD1 inhibitor.", + "Two cases were associated with nivolumab/ipilimumab combination.", + "Three cases were associated with an anti-PD1 regimen.", + "Five cases were associated with anti-CTLA4 treatment.", + "Granulomatous/sarcoid-like reactions have been described in different organs of cancer patients treated with ICPIs.", + "Lungs, lymph nodes, and skin were the main tissues with granuloma formation.", + "Melanoma was the main underlying malignancy." + ], + "summary": "A 63-year-old female patient with metastatic melanoma was admitted to the hospital with symptoms of nausea, persistent diarrhea and shivering fever under consecutive treatments with ICPIs, initially pembrolizumab and subsequently ipilimumab. Sigmoidoscopy was performed revealing mucosal edema, hyperemia and erosions of the rectum and sigmoid colon. Histological evaluation of sigmoid colon mucosa biopsies revealed an unusual colitis pattern characterized by multiple intracryptal granulomas attributed to ICPIs therapy. Steroids were administered and the patient recovered. ICPIs treatment was discontinued. The patient was subsequently treated with chemotherapy but follow up radiology showed disease progression. A re-challenge with another ICPI regimen was decided and the patient is currently under immunotherapy with stable disease regarding melanoma status and without any sign of colitis recurrence.", + "summary_subclaims": [ + "The patient is a 63-year-old female.", + "The patient has metastatic melanoma.", + "The patient was admitted to the hospital with symptoms of nausea, persistent diarrhea and shivering fever.", + "The patient was under consecutive treatments with ICPIs.", + "The patient initially received pembrolizumab.", + "The patient subsequently received ipilimumab.", + "Sigmoidoscopy was performed.", + "Sigmoidoscopy revealed mucosal edema.", + "Sigmoidoscopy revealed hyperemia.", + "Sigmoidoscopy revealed erosions of the rectum and sigmoid colon.", + "Histological evaluation of sigmoid colon mucosa biopsies revealed an unusual colitis pattern.", + "The colitis pattern was characterized by multiple intracryptal granulomas.", + "The granulomas were attributed to ICPIs therapy.", + "Steroids were administered.", + "The patient recovered.", + "ICPIs treatment was discontinued.", + "The patient was subsequently treated with chemotherapy.", + "Follow up radiology showed disease progression.", + "A re-challenge with another ICPI regimen was decided.", + "The patient is currently under immunotherapy.", + "The patient has stable disease regarding melanoma status.", + "The patient has no sign of colitis recurrence." + ] + }, + { + "id": "multiclinsum_test_1085_en.txt", + "fulltext": "We report the case of a 43-year-old black woman admitted to the surgical emergency department for abdominal pain with inability to pass gas or stool, evolving for 3 days. She came from a rural community, without a health care structure, located about 100 km from the urban center. The anamnesis found menarche at 16 years old, an irregular menstrual cycle, a previous gestation and parity about 18 years ago, and a child who died at the age of 1 year. Our patient, divorced for 15 years, had reported an abdominal mass evolving for several years (about 10 years) with chronic constipation. The date of the last menstruation was not known. Our patient concealed any notion of sexual intercourse. On admittance to the surgical emergency department, our patient had a bad general condition and clinical anemia. A physical examination of her abdomen noted a widespread distension with an irregular, polylobed mass occupying the entire umbilical region. The supraumbilical stage was tympanic to percussion with elastic resistance to palpation. The rectal examination found an empty rectum, and the mass was perceptible in Douglas’s pouch. At the vaginal pelvic examination, we found the same mass and a finger holster was clean.\nAn erect abdominal X-ray noted an ileocolic distension with some hydroaerial levels and a pelvic opacity . The diagnosis of AIO by a tumor was evoked, and emergency laparotomy was indicated. The biological examination noted: anemia at 10 g/dL, and slightly altered renal function (a uremia level of 12 mmol/L, a serum creatinine level of 190 μmol/L).\nA nasogastric tube, a urinary catheter, and a large venous line were installed for resuscitation. A median laparotomy allowed the aspiration of 1.2 L of blood. Exploration noted a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The largest myoma previa adhered to the rectosigmoid hinge and compressed it , explaining the extrinsic obstruction of the colon. A total hysterectomy was performed. The surgical specimen containing the uterus, myomas and annex weighed 4.5 kg . The most voluminous myoma was 18 cm wide and 23 cm long. The surgical recovery was uneventful, and our patient was discharged on postoperative day 12. Our patient was informed that she could no longer have children. Our patient was very satisfied with the disappearance of this abdominal mass, which hampered her daily activities. A histologic examination confirmed a ruptured ectopic pregnancy and myofibroma without signs of malignancy.", + "fulltext_subclaims": [ + "The patient is a 43-year-old black woman.", + "She was admitted to the surgical emergency department for abdominal pain with inability to pass gas or stool.", + "The symptoms had been evolving for 3 days.", + "She came from a rural community.", + "The community had no health care structure.", + "The community was located about 100 km from the urban center.", + "The anamnesis found menarche at 16 years old.", + "The anamnesis found an irregular menstrual cycle.", + "The anamnesis found a previous gestation and parity about 18 years ago.", + "The anamnesis found a child who died at the age of 1 year.", + "The patient had reported an abdominal mass evolving for several years.", + "The abdominal mass had been present for about 10 years.", + "The patient had chronic constipation.", + "The date of the last menstruation was not known.", + "The patient concealed any notion of sexual intercourse.", + "On admittance, the patient had a bad general condition.", + "On admittance, the patient had clinical anemia.", + "A physical examination of the abdomen noted a widespread distension.", + "The physical examination noted an irregular, polylobed mass occupying the entire umbilical region.", + "The supraumbilical stage was tympanic to percussion.", + "The rectal examination found an empty rectum.", + "The mass was perceptible in Douglas’s pouch.", + "An erect abdominal X-ray noted an ileocolic distension.", + "The diagnosis of AIO by a tumor was evoked.", + "Emergency laparotomy was indicated.", + "The biological examination noted anemia at 10 g/dL.", + "The biological examination noted a uremia level of 12 mmol/L.", + "The biological examination noted a serum creatinine level of 190 μmol/L.", + "A nasogastric tube was installed for resuscitation.", + "A urinary catheter was installed for resuscitation.", + "A large venous line was installed for resuscitation.", + "A median laparotomy allowed the aspiration of 1.2 L of blood.", + "Exploration noted a ruptured right tubal ectopic pregnancy.", + "Exploration noted a polymyomatous uterus.", + "The largest myoma previa adhered to the rectosigmoid hinge.", + "The myoma compressed the rectosigmoid hinge.", + "A total hysterectomy was performed.", + "The surgical specimen weighed 4.5 kg.", + "The most voluminous myoma was 18 cm wide.", + "The most voluminous myoma was 23 cm long.", + "The surgical recovery was uneventful.", + "The patient was discharged on postoperative day 12.", + "The patient was informed that she could no longer have children.", + "The patient was very satisfied with the disappearance of the abdominal mass.", + "A histologic examination confirmed a ruptured ectopic pregnancy.", + "A histologic examination confirmed myofibroma without signs of malignancy." + ], + "summary": "This is the case report of a 43-year-old primiparous black woman from a rural area, who was admitted to the surgical emergency department for acute intestinal obstruction. At examination on admittance, our patient had a bad general condition with clinical anemia. She had an occlusive syndrome that had been evolving for 3 days. A physical examination of her abdomen showed a widespread distension with an irregular and polylobed solid mass occupying the whole of the lower-umbilical and hypogastric area. A rectal examination found an empty rectum, and the mass was perceptible in Douglas's pouch. At the vaginal examination, we found the same mass and a finger holster was clean. The diagnosis of intestinal occlusion by a tumor was retained. The laparotomy revealed a distended intestine, a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The most massive previa leiomyoma was adhering and compressing the rectal and sigmoidal hinge. A total hysterectomy was performed and histopathological examination of specimens confirmed myoma and ectopic pregnancy. The surgical follow-up was uneventful, and our patient was discharged on postoperative day 12.", + "summary_subclaims": [ + "This is the case report of a 43-year-old primiparous black woman from a rural area.", + "She was admitted to the surgical emergency department for acute intestinal obstruction.", + "At examination on admittance, our patient had a bad general condition with clinical anemia.", + "She had an occlusive syndrome that had been evolving for 3 days.", + "A physical examination of her abdomen showed a widespread distension with an irregular and polylobed solid mass occupying the whole of the lower-umbilical and hypogastric area.", + "A rectal examination found an empty rectum.", + "The mass was perceptible in Douglas's pouch.", + "At the vaginal examination, we found the same mass.", + "A finger holster was clean.", + "The diagnosis of intestinal occlusion by a tumor was retained.", + "The laparotomy revealed a distended intestine.", + "The laparotomy revealed a ruptured right tubal ectopic pregnancy.", + "The laparotomy revealed a polymyomatous uterus.", + "The most massive previa leiomyoma was adhering and compressing the rectal and sigmoidal hinge.", + "A total hysterectomy was performed.", + "Histopathological examination of specimens confirmed myoma.", + "Histopathological examination of specimens confirmed ectopic pregnancy.", + "The surgical follow-up was uneventful.", + "Our patient was discharged on postoperative day 12." + ] + }, + { + "id": "multiclinsum_test_2695_en.txt", + "fulltext": "A 77-year-old man presented with multiple pancreatic tumor lesions with a maximum diameter of 13.8 mm. The lesions had been identified by periodic ultrasonographic check-ups. He had undergone laparoscopy-assisted right nephrectomy for renal cell carcinoma 11 years previously and had since been free of tumor recurrence. His medical history also included dyslipidemia; however, he had no history of diabetes. Laboratory data showed no remarkable changes, including changes in tumor markers. Contrast-enhanced computed tomography (CT) revealed multiple (at least 10) hypovascular tumors located in the whole pancreas and swollen regional lymph nodes . Endoscopic ultrasonography depicted these lesions as hypoechoic tumors, and fine-needle aspiration proved that they were pancreatic metastases from renal cell carcinoma. Extrapancreatic organ metastasis was not detected by positron emission tomography. Thus, TP with regional lymph node dissection was performed as a curative treatment. The pancreas was soft. The operation time was 425 min, and the blood loss was 510 mL.\nArterial blood gas analysis at the end of the operation was within normal limits (pH, 7.37; pCO2, 36.0 mmHg; HCO3, 20.5 mEq/L; and base excess, − 3.9). After the patient had recovered from general anesthesia, he was transferred from the operating room to the intensive care unit. His vital signs and consciousness were normal immediately after this transfer. Fifteen minutes after entering the intensive care unit, however, he suddenly and completely lost consciousness and stopped breathing with no prodrome. His oxygen saturation dropped to 34% despite oxygenation at 3 L/min using a face-covering mask; therefore, high-flow oxygen was administered. He spontaneously regained consciousness after 4 min. Arterial blood gas analysis during this episode revealed mild metabolic acidosis (pH, 7.34; pCO2, 42.6 mmHg; and HCO3, 22.1 mEq/L). His lactate (2.6 mmol/L) and glucose (233 mg/dL) concentrations were higher than upon completion of the operation. Intravenous administration of fentanyl was terminated because of the concern that it may prevent spontaneous ventilation. Ten minutes after recovery of consciousness, the acidosis became exacerbated (pH, 7.29; pCO2, 44.5 mmHg; and HCO3, 20.8 mmHg). The patient’s lactate (3.1 mmol/L) and glucose (246 mg/dL) concentrations increased further. Twenty minutes after the first episode, he lost consciousness and stopped breathing again. Because his consciousness did not improve (unlike the first episode), reintubation for forced ventilation was performed. Blood gas analysis showed severe acidosis and hyperglycemia (pH, 7.21; pCO2, 55.9 mmHg; HCO3, 21.4 mmHg; base excess, − 6.7; lactate, 2.9 mmol/L; and glucose, 302 mg/dL). His serum ketone (β-hydroxybutyrate) concentration after the second episode of TLOC was high (0.713 mmol/L). Head CT after reintubation revealed no remarkable change. An electrocardiogram and transthoracic echocardiogram revealed no arrhythmia or abnormal cardiac function. Continuous electrocardiographic monitoring and arterial pressure measurement throughout the episodes showed no arrhythmia or cardiac shock. Continuous insulin infusion was initiated immediately after the second episode of TLOC. The patient’s blood glucose and pH returned to the normal range, and he regained consciousness and spontaneous ventilation. The patient’s clinical course is summarized in Fig. . Estimated concentration of fentanyl at the central nerve system and plasma analyzed by Tivatrainer (version 9.1, Digital River GmbH Scheidtweilerstr, Cologne, Germany) is shown in Fig. . The next day, he was extubated without needing reintubation. An electroencephalogram recorded on postoperative day (POD) 10 revealed no signs of epilepsy or other neurological diseases. Head magnetic resonance imaging and angiography on POD 11 were devoid of sites of infarction or signs of epilepsy, and the blood vessels in the head and neck were clearly depicted without narrowing. On POD 31, the patient was discharged from the hospital with no severe postoperative complications besides the above-mentioned episodes. The final pathological diagnosis was metastases of clear cell renal cell carcinoma to the pancreas and surrounding lymph nodes with a negative surgical margin. He underwent no adjuvant therapy, and he was alive without recurrence 6 months after surgery. At the time of this writing, he had experienced no loss of consciousness since then.", + "fulltext_subclaims": [ + "The patient was a 77-year-old man.", + "He had multiple pancreatic tumor lesions with a maximum diameter of 13.8 mm.", + "The lesions had been identified by periodic ultrasonographic check-ups.", + "He had undergone laparoscopy-assisted right nephrectomy for renal cell carcinoma 11 years previously.", + "He had been free of tumor recurrence since the nephrectomy.", + "His medical history included dyslipidemia.", + "He had no history of diabetes.", + "Laboratory data showed no remarkable changes.", + "Contrast-enhanced computed tomography revealed multiple (at least 10) hypovascular tumors located in the whole pancreas.", + "Contrast-enhanced computed tomography showed swollen regional lymph nodes.", + "Endoscopic ultrasonography depicted the lesions as hypoechoic tumors.", + "Fine-needle aspiration proved that the lesions were pancreatic metastases from renal cell carcinoma.", + "Extrapancreatic organ metastasis was not detected by positron emission tomography.", + "TP with regional lymph node dissection was performed as a curative treatment.", + "The operation time was 425 min.", + "The blood loss was 510 mL.", + "Arterial blood gas analysis at the end of the operation was within normal limits.", + "The patient was transferred from the operating room to the intensive care unit.", + "His vital signs and consciousness were normal immediately after transfer.", + "Fifteen minutes after entering the intensive care unit, he suddenly and completely lost consciousness.", + "He stopped breathing with no prodrome.", + "His oxygen saturation dropped to 34% despite oxygenation at 3 L/min using a face-covering mask.", + "He spontaneously regained consciousness after 4 min.", + "Arterial blood gas analysis during this episode revealed mild metabolic acidosis.", + "His lactate concentration was higher than upon completion of the operation.", + "His glucose concentration was higher than upon completion of the operation.", + "Intravenous administration of fentanyl was terminated.", + "Ten minutes after recovery of consciousness, the acidosis became exacerbated.", + "The patient’s lactate concentration increased further.", + "The patient’s glucose concentration increased further.", + "Twenty minutes after the first episode, he lost consciousness and stopped breathing again.", + "Because his consciousness did not improve, reintubation for forced ventilation was performed.", + "Blood gas analysis showed severe acidosis and hyperglycemia.", + "His serum ketone (β-hydroxybutyrate) concentration after the second episode of TLOC was high.", + "Head CT after reintubation revealed no remarkable change.", + "An electrocardiogram and transthoracic echocardiogram revealed no arrhythmia or abnormal cardiac function.", + "Continuous electrocardiographic monitoring showed no arrhythmia.", + "Continuous arterial pressure measurement showed no cardiac shock.", + "Continuous insulin infusion was initiated immediately after the second episode of TLOC.", + "The patient’s blood glucose and pH returned to the normal range.", + "He regained consciousness and spontaneous ventilation.", + "The next day, he was extubated without needing reintubation.", + "An electroencephalogram recorded on postoperative day (POD) 10 revealed no signs of epilepsy or other neurological diseases.", + "Head magnetic resonance imaging and angiography on POD 11 were devoid of sites of infarction or signs of epilepsy.", + "The blood vessels in the head and neck were clearly depicted without narrowing.", + "On POD 31, the patient was discharged from the hospital.", + "The final pathological diagnosis was metastases of clear cell renal cell carcinoma to the pancreas and surrounding lymph nodes.", + "The surgical margin was negative.", + "He underwent no adjuvant therapy.", + "He was alive without recurrence 6 months after surgery.", + "At the time of this writing, he had experienced no loss of consciousness since then." + ], + "summary": "A 77-year-old man who had undergone right nephrectomy for renal cell carcinoma 11 years previously presented with multiple histologically diagnosed pancreatic metastases. The patient had no notable comorbidities, including diabetes. Because no extrapancreatic organ metastasis was identified, he underwent TP as a curative treatment. He awoke from anesthesia and was extubated without any problems in the operating room. However, 15 min after entering the intensive care unit, he suddenly lost consciousness and became apneic, resulting in reintubation. Blood gas analysis revealed an increased glucose concentration (302 mg/dL) and mixed acid-base disorder (pH of 7.21) due to insulin insufficiency and fentanyl administration. After induction of continuous intravenous insulin infusion and termination of fentanyl, the glucose concentration and pH gradually improved. He regained clear consciousness and spontaneous ventilation and was extubated the next day with no difficulties or complications.", + "summary_subclaims": [ + "The patient was a 77-year-old man.", + "He had undergone right nephrectomy for renal cell carcinoma 11 years previously.", + "He had multiple histologically diagnosed pancreatic metastases.", + "The patient had no notable comorbidities.", + "No extrapancreatic organ metastasis was identified.", + "He underwent TP as a curative treatment.", + "He awoke from anesthesia and was extubated without any problems in the operating room.", + "15 min after entering the intensive care unit, he suddenly lost consciousness and became apneic.", + "Blood gas analysis revealed an increased glucose concentration of 302 mg/dL.", + "Blood gas analysis revealed a pH of 7.21.", + "The mixed acid-base disorder was due to insulin insufficiency and fentanyl administration.", + "After induction of continuous intravenous insulin infusion and termination of fentanyl, the glucose concentration gradually improved.", + "After induction of continuous intravenous insulin infusion and termination of fentanyl, the pH gradually improved.", + "He regained clear consciousness and spontaneous ventilation.", + "He was extubated the next day with no difficulties or complications." + ] + }, + { + "id": "multiclinsum_test_3249_en.txt", + "fulltext": "52-year-old female patient, without comorbidities. Two years of disease evolution with localized pain (visual analogue scale [VAS] 9) on the distal phalanx of the left thumb, of a burning type, which increased with movement and with changes in temperature. Physical examination showed subungual pain, with mild volume increase and palpation of a radial-sided tumour. Ultrasound reported a highly vascularised nodular lesion without shadow or posterior reinforcement, circumscribed, hypoechoic and homogeneous of 3.00 × 2.10 mm on the medial edge of the distal phalanx of the first finger plus thickening of the synovial sheath; these are characteristic findings of glomus tumours. Surgical treatment was decided, which required glasses with two-fold magnification, regional block anaesthesia and ischaemia and H approach to the distal phalanx and transverse subungual. The nail tumour was removed and a white-yellowish tumour, well encapsulated and of the described dimensions, could be visualised. After exeresis, bone curettage and cauterisation of the vascular bed was performed to finally suture with monofilament nylon 4/0. A piece was sent for histopathological study. She attended the two-week follow-up appointment in the outpatient department, where surgical wound stitches were removed with adequate healing. Physical examination with ability to mobilise the distal interphalangeal joint (IFD) and 1-point VAS. The result of the histopathological study reported a glomus tumours of 3 × 2 mm.\n", + "fulltext_subclaims": [ + "The patient is a 52-year-old female.", + "The patient has no comorbidities.", + "The disease evolution has lasted two years.", + "The patient has localized pain on the distal phalanx of the left thumb.", + "The pain is rated as 9 on the visual analogue scale.", + "The pain is of a burning type.", + "The pain increases with movement.", + "The pain increases with changes in temperature.", + "Physical examination showed subungual pain.", + "Physical examination showed mild volume increase.", + "Physical examination showed palpation of a radial-sided tumour.", + "Ultrasound reported a highly vascularised nodular lesion.", + "The lesion is circumscribed, hypoechoic, and homogeneous.", + "The lesion measures 3.00 × 2.10 mm.", + "The lesion is located on the medial edge of the distal phalanx of the first finger.", + "There is thickening of the synovial sheath.", + "These findings are characteristic of glomus tumours.", + "Surgical treatment was decided.", + "The surgery required glasses with two-fold magnification.", + "The surgery used regional block anaesthesia and ischaemia.", + "The surgical approach was to the distal phalanx and transverse subungual.", + "A white-yellowish tumour, well encapsulated, was visualised.", + "The tumour measured 3 × 2 mm.", + "Bone curettage was performed.", + "Cauterisation of the vascular bed was performed.", + "The wound was sutured with monofilament nylon 4/0.", + "A piece was sent for histopathological study.", + "The patient attended a two-week follow-up appointment.", + "Surgical wound stitches were removed.", + "The surgical wound showed adequate healing.", + "The patient could mobilise the distal interphalangeal joint.", + "The pain was rated as 1 point on the visual analogue scale.", + "The histopathological study reported a glomus tumour." + ], + "summary": "52-year-old female patient who reported chronic, burning pain radiating to the distal phalanx of the thumb with no traumatic history, which had been present for two years and limited her daily activities. The exploration was complemented with interphalangeal Doppler ultrasound, which is an excellent alternative due to its easy accessibility. A glomus tumor in the interphalangeal phalanx of the thumb was diagnosed. A H-approach was performed on the interphalangeal fold with subungual dissection and resection of the tumoral piece and follow-up by an external consultation where the surgical wound was found to be healing adequately. Physical exploration with the ability to mobilize the interphalangeal distal joint (IFD) and visual analogue scale (VAS) of 1 point. The anatomopathological evaluation reported the existence of a glomus tumor.\n", + "summary_subclaims": [ + "The patient is a 52-year-old female.", + "The patient reported chronic, burning pain radiating to the distal phalanx of the thumb.", + "The pain had been present for two years.", + "There was no traumatic history.", + "The pain limited her daily activities.", + "Interphalangeal Doppler ultrasound was performed.", + "Interphalangeal Doppler ultrasound is an excellent alternative due to its easy accessibility.", + "A glomus tumor in the interphalangeal phalanx of the thumb was diagnosed.", + "A H-approach was performed on the interphalangeal fold.", + "Subungual dissection and resection of the tumoral piece were performed.", + "The surgical wound was found to be healing adequately.", + "The patient was able to mobilize the interphalangeal distal joint.", + "The visual analogue scale (VAS) was 1 point.", + "The anatomopathological evaluation reported the existence of a glomus tumor." + ] + }, + { + "id": "multiclinsum_test_1980_en.txt", + "fulltext": "A 65-year-old female was relatively well before and had history of diabetes mellitus without medical control. This admission, she suffered from sudden onset of retrosternal chest pain at rest and came to our emergency room for help. The pain was tight in characteristic and radiation to the epigastric area. On physical examination, she had a blood pressure of 125/88 mmHg, heart rate of 77/minutes, and clear consciousness. Crackle could be heard in both lung fields and grade three holosystolic murmur was heard in the left lower sternal border. The blood tests revealed creatinine of 0.9 mg/dl, creatinine kinase of 251 IU/L, creatinine kinase MB of 31.11 ng/ml, and Troponin T of 0.800. The peak of serial cardiac enzymes values were as followed: creatinine kinase 500, creatinine kinase MB 40 and Troponin T 1.09 which noted 24 hours after onset. Chest X-ray showed mild pulmonary congestion. An ECG showed rightward axis, normal QT interval with QTc of 422 ms, and non-significant ST-T elevation (0.05 mv) at leads I, aVL, and V5 without dynamic change in the serial follow-up ECGs. Under the impression of non-ST elevation myocardial infarction, conservative treatment with anti-thrombotic and anti-platelet regimens was prescribed. The echocardiography showed impaired global LV systolic performance with mid-septum hypokinesis and akinesis of mid-anterior to apical-anterior wall, but well preserved basal septal contractility. Cardiac catheterization was performed on the 7th day. Coronary angiogram revealed no significant stenonsis on coronary arteries and left ventriculography showed anterior wall akinesis, apical hypokinesis and slight basal hyperkinesis of left ventricle . The patient was improved after supportive care and follow-up echocardiography showed complete recovery of left ventricular systolic function without abnormal regional wall motion 2 weeks later.", + "fulltext_subclaims": [ + "The patient was a 65-year-old female.", + "She had a history of diabetes mellitus without medical control.", + "She suffered from sudden onset of retrosternal chest pain at rest.", + "The pain was tight in characteristic.", + "The pain radiated to the epigastric area.", + "On physical examination, she had a blood pressure of 125/88 mmHg.", + "Crackle could be heard in both lung fields.", + "A grade three holosystolic murmur was heard in the left lower sternal border.", + "The blood tests revealed creatinine of 0.9 mg/dl.", + "The blood tests revealed creatinine kinase of 251 IU/L.", + "The blood tests revealed creatinine kinase MB of 31.11 ng/ml.", + "The blood tests revealed Troponin T of 0.800.", + "The peak of serial cardiac enzymes values were noted 24 hours after onset.", + "Chest X-ray showed mild pulmonary congestion.", + "An ECG showed rightward axis.", + "An ECG showed normal QT interval with QTc of 422 ms.", + "An ECG showed non-significant ST-T elevation (0.05 mv) at leads I, aVL, and V5.", + "The ECG showed no dynamic change in the serial follow-up ECGs.", + "The impression was non-ST elevation myocardial infarction.", + "Conservative treatment with anti-thrombotic and anti-platelet regimens was prescribed.", + "Echocardiography showed impaired global LV systolic performance.", + "Echocardiography showed mid-septum hypokinesis.", + "Echocardiography showed akinesis of mid-anterior to apical-anterior wall.", + "Echocardiography showed well preserved basal septal contractility.", + "Cardiac catheterization was performed on the 7th day.", + "Coronary angiogram revealed no significant stenosis on coronary arteries.", + "Left ventriculography showed anterior wall akinesis.", + "Left ventriculography showed apical hypokinesis.", + "Follow-up echocardiography showed complete recovery of left ventricular systolic function.", + "Follow-up echocardiography showed no abnormal regional wall motion 2 weeks later." + ], + "summary": "We reported a case with atypical presentation of \"takotsubo cardiomyopathy\" without ST segment elevation, but with severe transient left ventricular dysfunction.", + "summary_subclaims": [ + "We reported a case with atypical presentation of \"takotsubo cardiomyopathy\".", + "The case did not have ST segment elevation.", + "The case had severe transient left ventricular dysfunction." + ] + }, + { + "id": "multiclinsum_test_1446_en.txt", + "fulltext": "The initial dermatologic consultation of our 61-year-old Caucasian female patient occurred two years ago when she presented with a reddish, indolent nodule of the scalp 5 mm in diameter with local alopecia that she had noticed for the first time four months before. A small punch biopsy of her scalp exhibited solid proliferations of monomorphous tumor cells with a cytoplasm rich in vacuoles and sebaceous differentiation. Subepidermal spreading of the cells was knobby; a sclerodermiform-like spreading was predominant within the reticular dermis. The cells expressed pancytokeratin (MNF116) and epithelial membrane antigen (EMA) but staining for BerEP4 and carcino embryonal antigen (CEA) was negative. Therefore, we initially established the diagnosis of a primary cutaneous carcinoma with sebaceous differentiation. Upon thorough review of our patient's personal history she informed us of a previous diagnosis of a poorly differentiated invasive solid ductal breast carcinoma of her left breast five years previously, which was positive for estrogen receptor (ER) and progesterone receptor (PR), but negative for human epidermal growth factor receptor 2 (HER-2/neu) . At that time, our patient underwent ablatio mammae left sided with ipsilateral dissection of the axillary lymph nodes (18 out of 19 lymph nodes being positive) and contralateral plastic surgery reduction of the right breast, followed by radiochemotherapy with paclitaxel. Regular follow-up over five years showed no clinical or mammographic recurrence of the disease.\nFurther examination of our patient was then initiated. It showed a second moderately differentiated invasive ductal breast carcinoma of her right breast with a sonographic tumor thickness of 5 mm . Computed chest tomography revealed multiple pulmonary and lymphatic metastatic lesions within the ipsilateral axillary lymph nodes. This ductal breast carcinoma was positive for ER and PR. Ki67 expression demonstrated that 20% of the tumor cells were proliferating. No overexpression of HER-2/neu was observed.\nThe tumor of the scalp was surgically removed in our department. Histopathological examination of this tissue showed a solid tumor consisting of large monomorphous cell proliferations with sebaceous differentiation, similar to the features found in the previous biopsy . The immunophenotype was identical. Additionally, the cutaneous tumor cells were positive for ER and PR, with no evident overexpression of HER-2/neu . Moreover we performed an adipophilin stain that was negative in the tumor cell fraction. Sebaceous glands expressing adipophilin served as internal control .\nOur patient received axillary right sentinel node biopsy, ablatio mammae right, and one cycle of chemotherapy with paclitaxel and bevacizumab, but died due to sepsis two months after the diagnosis of cutaneous metastatic breast carcinoma. Detailed clinical data are given in table .\nWe were able to establish the final diagnosis of metastatic breast cancer with the histologic appearance of a sebaceous differentiated primary cutaneous carcinoma. Our patient had bilateral ductal breast cancer with identical hormone receptor status within five years. It remains unclear whether the cutaneous metastasis originated from the initially diagnosed breast cancer of her left mammary or from the second ductal carcinoma of her right breast.", + "fulltext_subclaims": [ + "The patient is a 61-year-old Caucasian female.", + "The initial dermatologic consultation occurred two years ago.", + "She presented with a reddish, indolent nodule of the scalp 5 mm in diameter with local alopecia.", + "She had noticed the scalp nodule for the first time four months before the consultation.", + "A small punch biopsy of her scalp exhibited solid proliferations of monomorphous tumor cells with a cytoplasm rich in vacuoles and sebaceous differentiation.", + "Subepidermal spreading of the cells was knobby.", + "A sclerodermiform-like spreading was predominant within the reticular dermis.", + "The cells expressed pancytokeratin (MNF116) and epithelial membrane antigen (EMA).", + "Staining for BerEP4 and carcino embryonal antigen (CEA) was negative.", + "The initial diagnosis was a primary cutaneous carcinoma with sebaceous differentiation.", + "The patient had a previous diagnosis of a poorly differentiated invasive solid ductal breast carcinoma of her left breast five years previously.", + "The breast carcinoma was positive for estrogen receptor (ER) and progesterone receptor (PR), but negative for human epidermal growth factor receptor 2 (HER-2/neu).", + "The patient underwent ablatio mammae left sided with ipsilateral dissection of the axillary lymph nodes.", + "18 out of 19 lymph nodes were positive.", + "The patient had contralateral plastic surgery reduction of the right breast.", + "The patient received radiochemotherapy with paclitaxel.", + "Regular follow-up over five years showed no clinical or mammographic recurrence of the disease.", + "Further examination showed a second moderately differentiated invasive ductal breast carcinoma of her right breast.", + "The sonographic tumor thickness of the right breast carcinoma was 5 mm.", + "Computed chest tomography revealed multiple pulmonary and lymphatic metastatic lesions within the ipsilateral axillary lymph nodes.", + "The ductal breast carcinoma was positive for ER and PR.", + "Ki67 expression demonstrated that 20% of the tumor cells were proliferating.", + "No overexpression of HER-2/neu was observed.", + "The tumor of the scalp was surgically removed.", + "Histopathological examination showed a solid tumor consisting of large monomorphous cell proliferations with sebaceous differentiation.", + "The immunophenotype of the scalp tumor was identical to the previous biopsy.", + "The cutaneous tumor cells were positive for ER and PR.", + "No evident overexpression of HER-2/neu was observed in the cutaneous tumor.", + "An adipophilin stain was negative in the tumor cell fraction.", + "Sebaceous glands expressing adipophilin served as internal control.", + "The patient received axillary right sentinel node biopsy.", + "The patient had ablatio mammae right.", + "The patient received one cycle of chemotherapy with paclitaxel and bevacizumab.", + "The patient died due to sepsis two months after the diagnosis of cutaneous metastatic breast carcinoma.", + "The final diagnosis was metastatic breast cancer with the histologic appearance of a sebaceous differentiated primary cutaneous carcinoma.", + "The patient had bilateral ductal breast cancer with identical hormone receptor status within five years.", + "It remains unclear whether the cutaneous metastasis originated from the initially diagnosed breast cancer of her left mammary or from the second ductal carcinoma of her right breast." + ], + "summary": "We report the case of a 61-year-old Caucasian woman with cutaneous metastases of a bilateral ductal breast carcinoma that in histopathological examination mimicked an adnexal neoplasm with sebaceous differentiation.", + "summary_subclaims": [ + "The patient was a 61-year-old Caucasian woman.", + "The patient had cutaneous metastases of a bilateral ductal breast carcinoma.", + "The histopathological examination showed the metastases mimicked an adnexal neoplasm.", + "The histopathological examination showed the metastases had sebaceous differentiation." + ] + }, + { + "id": "multiclinsum_test_3067_en.txt", + "fulltext": "A 13-year-old male presented to the emergency department with a four-day history of right inguinoscrotal pain and nausea. He had no prior medical history. Genital examination revealed a tender, freely movable mass in the right scrotum, positioned above the testicle, while both testes were fully descended and appeared symmetrical in size and structure.\n\nGiven the acute presentation, Doppler ultrasonography revealed a 48 × 19 mm heterogeneous soft tissue mass in the spermatic cord adjacent to the right testicle, with no vascular flow. Tumor markers (β-HCG, AFP, LDH, and CEA) were all within normal limits, reducing suspicion of malignancy.\n\nDue to persistent pain, imaging findings of an avascular mass, and the potential risk of testicular compromise, urgent surgical exploration was deemed necessary. The patient, initially apprehensive about surgery and the potential risk of testicular loss, provided informed consent following a detailed discussion of risks and benefits.\n\nInguinal exploration identified a 5 × 2 cm solid, white mass within the tunica vaginalis. The mass was excised relatively easily after severing its vascular connections to the pampiniform plexus. The testicle was intact, and no additional intervention was required. A right herniotomy and high ligation were performed concurrently.\n\nPostoperatively, the patient was discharged with a structured follow-up plan, including monthly and six-monthly evaluations. Physical examination and ultrasonographic follow-up demonstrated no recurrence. The patient reported no ongoing symptoms during subsequent clinic visits.\n\nHistopathological examination confirmed the diagnosis of fibrolipoma, characterized by collagen-rich stroma enveloping lobules of mature adipose tissue. Macroscopically, the lesion measured 5 × 4 × 2 cm, was partially encapsulated and exhibited a grayish-yellow cut surface. Microscopically, elongated spindle cells were observed within the collagenized stroma, interspersed with mature adipocytes and vascular channels, without evidence of atypia.\n\nImmunohistochemical analysis demonstrated positive staining with CD34 in some stromal areas and negative staining in others. Positive staining with CD117 was rare in mast cells, while positive staining with CD68 was rarely noted in histiocytes. Positive staining with SMA was observed exclusively in vascular walls, while positive staining with S-100 protein was observed in fatty tissues. Negative staining was observed with β-catenin, PanCK, MelanA, HMB-45, and Desmin.", + "fulltext_subclaims": [ + "The patient is a 13-year-old male.", + "He presented with a four-day history of right inguinoscrotal pain.", + "He had nausea.", + "Genital examination revealed a tender, freely movable mass in the right scrotum.", + "The mass was positioned above the testicle.", + "Both testes were fully descended.", + "Doppler ultrasonography revealed a 48 × 19 mm heterogeneous soft tissue mass in the spermatic cord.", + "The mass was adjacent to the right testicle.", + "The mass showed no vascular flow.", + "Tumor markers (β-HCG, AFP, LDH, and CEA) were all within normal limits.", + "Urgent surgical exploration was deemed necessary.", + "Inguinal exploration identified a 5 × 2 cm solid, white mass within the tunica vaginalis.", + "The mass was excised after severing its vascular connections to the pampiniform plexus.", + "A right herniotomy and high ligation were performed.", + "The testicle was intact.", + "Histopathological examination confirmed the diagnosis of fibrolipoma.", + "The lesion measured 5 × 4 × 2 cm.", + "The lesion was partially encapsulated.", + "The cut surface was grayish-yellow.", + "Microscopically, elongated spindle cells were observed within the collagenized stroma.", + "The stroma was interspersed with mature adipocytes and vascular channels.", + "There was no evidence of atypia.", + "Immunohistochemical analysis demonstrated positive staining with CD34 in some stromal areas.", + "Positive staining with CD68 was rarely noted in histiocytes.", + "Positive staining with S-100 protein was observed in fatty tissues.", + "Negative staining was observed with β-catenin.", + "The patient was discharged with a structured follow-up plan.", + "Physical examination and ultrasonographic follow-up demonstrated no recurrence.", + "The patient reported no ongoing symptoms during subsequent clinic visits." + ], + "summary": " male patient, aged 13, arrived at the emergency department complaining of right inguinoscrotal pain and nausea for the past four days. The genital examination of the patient revealed a tender, freely movable mass located in the right scrotum above the testicle. Doppler scrotal ultrasound demonstrated a soft tissue structure measuring 48 × 19 mm with heterogeneity and absence of vascular activity located along the spermatic cord in proximity to the right testicle. Right scrotal tenderness and absence of blood supply on Doppler ultrasound indicated emergency surgical intervention, considering the possibility of torsion in an accessory testicle, more frequently encountered in pediatrics. Surgical exploration of the inguinal region and mass excision were conducted. The pathology report determined a tumor exhibiting collagenized tissues surrounding fatty lobules, indicative of a fibrolipoma.", + "summary_subclaims": [ + "A 13-year-old male patient arrived at the emergency department complaining of right inguinoscrotal pain and nausea for the past four days.", + "The genital examination revealed a tender, freely movable mass located in the right scrotum above the testicle.", + "Doppler scrotal ultrasound demonstrated a soft tissue structure measuring 48 × 19 mm with heterogeneity and absence of vascular activity.", + "The soft tissue structure was located along the spermatic cord in proximity to the right testicle.", + "Right scrotal tenderness and absence of blood supply on Doppler ultrasound indicated emergency surgical intervention.", + "The possibility of torsion in an accessory testicle was considered.", + "Surgical exploration of the inguinal region and mass excision were conducted.", + "The pathology report determined a tumor exhibiting collagenized tissues surrounding fatty lobules.", + "The tumor was indicative of a fibrolipoma." + ] + }, + { + "id": "multiclinsum_test_990_en.txt", + "fulltext": "A 12-year-old girl presented with non-progressive congenital flexion deformities of bilateral elbows and complaints of difficulty in writing, typing, jogging, and difficulty in using the Indian toilet such that she had to sit with one leg extended for balance. She was the firstborn child of a second-degree consanguineous marriage. Her mother gave a history of delayed and decreased fetal movements during pregnancy. Her motor milestones were delayed though social adaptive and language milestones were normal. She was good at academics. She had attained menarche at the age of 12 years and has normal menstrual cycles. Family history was unremarkable. On clinical examination, she had prominence in the suprascapular region on both sides with trapezii contracture and mild-to-moderate restriction of cervical spine range of motion in rotation and lateral bending. She had 20° of internal rotation deformity bilaterally and abduction was restricted to 120° at both the shoulders. She had 22° of fixed flexion deformity at the left elbow and 20° at the right elbow. Bilateral passive forearm supination was restricted to 60° with passive wrist dorsiflexion restricted to 35° on both sides. Clinodactyly was noticed in bilateral ring fingers and her fingers were hyperextensible at the interphalangeal joints. Otherwise, there were no signs of generalized ligamentous laxity. She had hypoplastic left thenar eminence with MRC Grade III power of the thenar muscles. She had bilateral tendo Achilles contractures with no passive dorsiflexion possible from neutral though the plantar flexion was full. She had a propulsive gait with a restricted arm swing on both sides. Mirror movements were demonstrated in bilateral fingers, elbows, toes, and ankles. ( & ) Mirror movements of the toes and fingers worsened with fatigue, but at the elbows and ankles, the mirror movements became less frequent as the voluntary movements were continued. Neurological examination was otherwise normal. Her height for her age was normal. There were no craniofacial malformations, hearing impairment, or visual defects.\nX-rays and 3-D computed tomography (CT) scan revealed bilateral Rigault Grade II Sprengel deformities and mild scoliosis at the cervical spine segment, cervicothoracic junction, and thoracolumbar junction . There was no fusion at any vertebral level. MRI revealed no central nervous system (CNS) or spinal cord malformations. Ultrasonography revealed no renal or genitourinary anomalies. ECHO showed mild aortic regurgitation.\nShe started on regular joint range of motion exercises, muscle stretching and strengthening physiotherapy, and retraining therapy with techniques for increasing wanted movements while focusing on restricting unwanted movements.\nHer frequency of mirror movements decreased and writing and typing co-ordination was getting better. She is compliant with therapy and on regular follow-up.", + "fulltext_subclaims": [ + "The patient is a 12-year-old girl.", + "She presented with non-progressive congenital flexion deformities of bilateral elbows.", + "She had difficulty in writing.", + "She had difficulty in typing.", + "She had difficulty in jogging.", + "She had difficulty in using the Indian toilet.", + "She had to sit with one leg extended for balance.", + "She was the firstborn child of a second-degree consanguineous marriage.", + "Her mother gave a history of delayed and decreased fetal movements during pregnancy.", + "Her motor milestones were delayed.", + "Her social adaptive and language milestones were normal.", + "She was good at academics.", + "She had attained menarche at the age of 12 years.", + "She has normal menstrual cycles.", + "Family history was unremarkable.", + "On clinical examination, she had prominence in the suprascapular region on both sides.", + "She had trapezii contracture.", + "She had mild-to-moderate restriction of cervical spine range of motion in rotation and lateral bending.", + "She had 20° of internal rotation deformity bilaterally.", + "Abduction was restricted to 120° at both the shoulders.", + "She had 22° of fixed flexion deformity at the left elbow.", + "She had 20° of fixed flexion deformity at the right elbow.", + "Bilateral passive forearm supination was restricted to 60°.", + "Bilateral passive wrist dorsiflexion was restricted to 35°.", + "Clinodactyly was noticed in bilateral ring fingers.", + "Her fingers were hyperextensible at the interphalangeal joints.", + "There were no signs of generalized ligamentous laxity.", + "She had hypoplastic left thenar eminence.", + "She had MRC Grade III power of the thenar muscles.", + "She had bilateral tendo Achilles contractures.", + "There was no passive dorsiflexion possible from neutral.", + "Plantar flexion was full.", + "She had a propulsive gait.", + "She had a restricted arm swing on both sides.", + "Mirror movements were demonstrated in bilateral fingers.", + "Mirror movements were demonstrated in bilateral elbows.", + "Mirror movements were demonstrated in bilateral toes.", + "Mirror movements were demonstrated in bilateral ankles.", + "Mirror movements of the toes and fingers worsened with fatigue.", + "Mirror movements at the elbows and ankles became less frequent as voluntary movements were continued.", + "Neurological examination was otherwise normal.", + "Her height for her age was normal.", + "There were no craniofacial malformations.", + "There was no hearing impairment.", + "There were no visual defects.", + "X-rays and 3-D CT scan revealed bilateral Rigault Grade II Sprengel deformities.", + "X-rays and 3-D CT scan revealed mild scoliosis at the cervical spine segment.", + "X-rays and 3-D CT scan revealed mild scoliosis at the cervicothoracic junction.", + "X-rays and 3-D CT scan revealed mild scoliosis at the thoracolumbar junction.", + "There was no fusion at any vertebral level.", + "MRI revealed no central nervous system (CNS) or spinal cord malformations.", + "Ultrasonography revealed no renal or genitourinary anomalies.", + "ECHO showed mild aortic regurgitation.", + "She started on regular joint range of motion exercises.", + "She started on muscle stretching and strengthening physiotherapy.", + "She started on retraining therapy with techniques for increasing wanted movements.", + "She started on retraining therapy with techniques for restricting unwanted movements.", + "Her frequency of mirror movements decreased.", + "Her writing and typing coordination was getting better.", + "She is compliant with therapy.", + "She is on regular follow-up." + ], + "summary": "We present a 12-year-old girl who presented with bilateral shoulder deformities and difficulty in coordination while writing. On examination, she was noted to have bilateral Sprengel deformities with flexion contractures of upper-limb joints and mirror movements of both upper and lower-limb joints.", + "summary_subclaims": [ + "The patient is a 12-year-old girl.", + "She presented with bilateral shoulder deformities.", + "She had difficulty in coordination while writing.", + "On examination, she was noted to have bilateral Sprengel deformities.", + "She had flexion contractures of upper-limb joints.", + "She had mirror movements of both upper and lower-limb joints." + ] + }, + { + "id": "multiclinsum_test_2777_en.txt", + "fulltext": "A 64-year old woman presented with neurogenic claudication and a maximum walking distance of 50 m. She described a radiating pain from the gluteal region to the lateral legs on both sides with a predominance for the left side, with a symptom onset approximately 1 year ago. Physical examination revealed intact motor function and decreased deep tendon reflexes on the left side. Medical history consisted of a discectomy L5/S1 on the right side 13 years ago. MRI revealed a lumbar spinal stenosis at the level of L4/5 . Patient underwent a standard microsurgical decompression L4/5 on the left side, including an over the top undercutting to the right side. During surgery, no dural tear was noted. On the first postoperative day she was mobilised and described significant improvement of the preoperative pain.\nTwo days later, during a turning movement in bed, she experienced a sudden sciatica radiating in her left leg. The intense pain was not responding to any analgesics and was only tolerated in a standing position leaning on the right leg. After frustrating attempts to stay in the horizontal position despite intravenous opioid administration, she was put under general anaesthesia for an MRI scan. The imaging revealed no hematoma or significant intraspinal compression. However, an unclear facet joint effusion L4/5 on the left side was apparent, which was not present preoperatively . The decision for exploratory revision surgery was therefore manly based on her clinical presentation as at this point the meaning of this effusion was unclear. In early stages of revision surgery cerebrospinal fluid (CSF) leakage was noted and after careful dissection, a nerve root herniation through a small lateral dural tear with entrapment in the facet joint gap was discovered . The herniated root was repositioned and the dural defect was repaired using stitches in a watertight fashion and a sealant matrix. Postoperatively the patient’s symptoms disappeared, she was mobilised after 2 days using a lumbar brace and the further clinical course was uneventful. As she did not develop any further clinical signs of potential segmental instability, fusion surgery was not deemed necessary.", + "fulltext_subclaims": [ + "The patient is a 64-year old woman.", + "She presented with neurogenic claudication.", + "Her maximum walking distance was 50 m.", + "She described radiating pain from the gluteal region to the lateral legs on both sides.", + "The pain had a predominance for the left side.", + "The symptom onset was approximately 1 year ago.", + "Physical examination revealed intact motor function.", + "Physical examination revealed decreased deep tendon reflexes on the left side.", + "Medical history consisted of a discectomy L5/S1 on the right side 13 years ago.", + "MRI revealed lumbar spinal stenosis at the level of L4/5.", + "The patient underwent a standard microsurgical decompression L4/5 on the left side.", + "The surgery included an over the top undercutting to the right side.", + "During surgery, no dural tear was noted.", + "On the first postoperative day, she was mobilised.", + "She described significant improvement of the preoperative pain.", + "Two days later, during a turning movement in bed, she experienced a sudden sciatica radiating in her left leg.", + "The intense pain was not responding to any analgesics.", + "The pain was only tolerated in a standing position leaning on the right leg.", + "She was put under general anaesthesia for an MRI scan.", + "The imaging revealed no hematoma.", + "The imaging revealed no significant intraspinal compression.", + "An unclear facet joint effusion L4/5 on the left side was apparent.", + "The effusion was not present preoperatively.", + "The decision for exploratory revision surgery was mainly based on her clinical presentation.", + "In early stages of revision surgery, cerebrospinal fluid leakage was noted.", + "A nerve root herniation through a small lateral dural tear with entrapment in the facet joint gap was discovered.", + "The herniated root was repositioned.", + "The dural defect was repaired using stitches in a watertight fashion.", + "A sealant matrix was used to repair the dural defect.", + "Postoperatively, the patient’s symptoms disappeared.", + "She was mobilised after 2 days using a lumbar brace.", + "The further clinical course was uneventful.", + "Fusion surgery was not deemed necessary." + ], + "summary": "We report a case of a patient who underwent lumbar decompression surgery and afterwards suffered a sudden intractable sciatica. Postoperative MRI showed a new facet joint gap effusion. During revision surgery an entrapped nerve root was found in the facet joint gap. In retrospective, the herniated nerve root is visible on postoperative MRI.", + "summary_subclaims": [ + "The patient underwent lumbar decompression surgery.", + "The patient suffered a sudden intractable sciatica after surgery.", + "Postoperative MRI showed a new facet joint gap effusion.", + "During revision surgery, an entrapped nerve root was found in the facet joint gap.", + "In retrospective, the herniated nerve root is visible on postoperative MRI." + ] + }, + { + "id": "multiclinsum_test_1527_en.txt", + "fulltext": "A man in his 50s was transferred by ambulance to a nearby physician because of rupture of gastric varices. At that time, he was diagnosed as having cirrhosis after chronic type B hepatitis and had been followed up with by the physician afterward. He was suspected to have developed HCC based on the imaging examination in December 2014, and he was referred to our hospital in March 2015 for further examination and treatment.\nAt the time of the first visit, his consciousness was clear, but he had a flapping tremor. He presented with notable conjunctival yellowing. His abdomen was flat and soft without tenderness. Laboratory test results indicated pancytopenia, a prolonged prothrombin time-international normalized ratio, hypoalbuminemia, and jaundice. The result of the indocyanine green retention test was as high as 36.5%. The alpha-fetoprotein level was within the normal range of 2.8 ng/mL, but the protein induced by vitamin K absence/antagonist-II (PIVKA-II) level was as high as 163 mAU/mL. He had cirrhosis after chronic type B hepatitis. The nucleotide analog (entecavir) was already prescribed by the previous physician, and the serological test result was positive for hepatitis B virus DNA . Abdominal dynamic computed tomography (CT) showed that the liver edge was blunt, and the surface was irregular. A 39-mm nodule, which was enhanced in the arterial phase and slightly washed out in the equilibrium phase, was located in segment 8 of the liver. Moreover, prominent splenomegaly, collateral circulation, and a small amount of ascites in the pelvis were confirmed . In gadolinium-ethoxybenzyl-diethilene-triamine-pentaacetic acid-enhanced dynamic magnetic resonance imaging, the 39-mm nodule, which was enhanced in the early phase and had a low signal in the hepatocyte phase, was also observed in segment 8 of the liver. Aside from this tumor, a small nodule measuring 9 mm in diameter showed the same contrast pattern in segment 8 of the liver . CT during arterial portography showed perfusion defects in the 2 HCCs, and CT during arteriography showed hypervascular tumors in the early phase and peripheral enhancement in the late phase, which was consistent with typical HCC contrast patterns . These HCCs were enhanced simultaneously during arteriography of A8, and obvious vascular invasion was not observed . No other lesions suspected of HCC were found in the liver. Upper gastrointestinal endoscopy revealed high-risk esophageal varices (Lm, F2, Cb, RC-sign [+]).\nOn the basis of these findings, we diagnosed the patient as having HCCs (cT3N0M0, clinical stage III) with severe liver damage. Regarding liver damage, the Child-Turcotte-Pugh classification was class C (11 points), and the Model for End-Stage Liver Disease score was 16 points, suggesting that he was a candidate for liver transplantation. Although there were 2 HCCs, one of them had a diameter exceeding 3 cm, which deviated from the Milan criteria. When applying the HCC therapy algorithm in Japan to this patient's comprehensive disease condition, only palliative care was recommended. Therefore, to determine treatment other than palliative care, we consulted with a transplant surgeon. As both HCCs were perfused with A8, locoregional therapy could be conducted to downstage HCC and maintain the liver reserve. Moreover, since this patient was relatively young, and his performance status was good, we considered liver transplantation as a curative treatment for HCC and sever liver damage. After confirming the wishes of the patient and his family, we decided to perform TACE following radical liver transplantation. Before these treatments, endoscopic varicocele ligation was performed for the esophageal varices. After confirming the disappearance of varices, lipiodol TACE was performed in segment 8 of the liver with 20 mg of epirubicin and gelatin sponges. There were neither postoperative complications nor changes in the Child-Turcotte-Pugh score. The PIVKA-II level decreased from 163 to 33 mAU/mL after TACE.\nAbdominal dynamic CT on day 60 after TACE showed sufficient lipiodol deposition in the 2 HCCs in segment 8, but a tiny lipiodol deposit-free area remained . On the basis of these findings, we determined that the progress of HCCs was successfully downstaged within the Milan criteria, and this patient underwent liver transplantation 110 days after TACE. Surgery was performed using a left lobe graft (graft weight, 298 g; graft-to-standard liver volume ratio, 25.8%). The operative time was 13 h and 53 min, and the bleeding volume was 7,885 mL.\nPathologically, most of the tumor was successfully treated by TACE, except for the small remaining HCC where lipiodol deposition was insufficient. The smaller HCC which was 9 mm before TACE was completed . Postoperatively, hyperbilirubinemia and ascetic accumulation due to small-for-size syndrome were temporarily observed but gradually improved after enlargement of the graft volume. This patient was discharged on day 35 after liver transplantation. Two and half years after transplantation, he remains alive without HCC recurrence or liver deterioration.", + "fulltext_subclaims": [ + "A man in his 50s was transferred by ambulance to a nearby physician because of rupture of gastric varices.", + "At that time, he was diagnosed as having cirrhosis after chronic type B hepatitis.", + "He had been followed up with by the physician afterward.", + "He was suspected to have developed HCC based on the imaging examination in December 2014.", + "He was referred to our hospital in March 2015 for further examination and treatment.", + "At the time of the first visit, his consciousness was clear.", + "He had a flapping tremor.", + "He presented with notable conjunctival yellowing.", + "His abdomen was flat and soft without tenderness.", + "Laboratory test results indicated pancytopenia.", + "The result of the indocyanine green retention test was as high as 36.5%.", + "The alpha-fetoprotein level was within the normal range of 2.8 ng/mL.", + "The PIVKA-II level was as high as 163 mAU/mL.", + "He had cirrhosis after chronic type B hepatitis.", + "The nucleotide analog (entecavir) was already prescribed by the previous physician.", + "The serological test result was positive for hepatitis B virus DNA.", + "Abdominal dynamic CT showed that the liver edge was blunt.", + "A 39-mm nodule, which was enhanced in the arterial phase and slightly washed out in the equilibrium phase, was located in segment 8 of the liver.", + "Prominent splenomegaly, collateral circulation, and a small amount of ascites in the pelvis were confirmed.", + "In gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced dynamic MRI, the 39-mm nodule, which was enhanced in the early phase and had a low signal in the hepatocyte phase, was also observed in segment 8 of the liver.", + "A small nodule measuring 9 mm in diameter showed the same contrast pattern in segment 8 of the liver.", + "CT during arterial portography showed perfusion defects in the 2 HCCs.", + "CT during arteriography showed hypervascular tumors in the early phase and peripheral enhancement in the late phase, which was consistent with typical HCC contrast patterns.", + "These HCCs were enhanced simultaneously during arteriography of A8.", + "No other lesions suspected of HCC were found in the liver.", + "Upper gastrointestinal endoscopy revealed high-risk esophageal varices (Lm, F2, Cb, RC-sign [+]).", + "We diagnosed the patient as having HCCs (cT3N0M0, clinical stage III) with severe liver damage.", + "The Child-Turcotte-Pugh classification was class C (11 points).", + "The Model for End-Stage Liver Disease score was 16 points.", + "One of the HCCs had a diameter exceeding 3 cm, which deviated from the Milan criteria.", + "Only palliative care was recommended.", + "We decided to perform TACE following radical liver transplantation.", + "Endoscopic varicocele ligation was performed for the esophageal varices.", + "Lipiodol TACE was performed in segment 8 of the liver with 20 mg of epirubicin and gelatin sponges.", + "The PIVKA-II level decreased from 163 to 33 mAU/mL after TACE.", + "Abdominal dynamic CT on day 60 after TACE showed sufficient lipiodol deposition in the 2 HCCs in segment 8.", + "We determined that the progress of HCCs was successfully downstaged within the Milan criteria.", + "This patient underwent liver transplantation 110 days after TACE.", + "Surgery was performed using a left lobe graft (graft weight, 298 g; graft-to-standard liver volume ratio, 25.8%).", + "The operative time was 13 h and 53 min.", + "The bleeding volume was 7,885 mL.", + "Most of the tumor was successfully treated by TACE, except for the small remaining HCC where lipiodol deposition was insufficient.", + "The smaller HCC which was 9 mm before TACE was completed.", + "Postoperatively, hyperbilirubinemia and ascetic accumulation due to small-for-size syndrome were temporarily observed.", + "This patient was discharged on day 35 after liver transplantation.", + "Two and half years after transplantation, he remains alive without HCC recurrence or liver deterioration." + ], + "summary": "A man in his 50s who was diagnosed as having two foci of HCC and advanced liver cirrhosis was referred to our hospital for further examination and treatment. Both foci of HCC were located in segment 8 of the liver and measured 39 and 9 mm. Endoscopy showed esophageal varices that had a high risk of bleeding. After endoscopic ligation of the esophageal varices, he underwent transcatheter arterial chemoembolization (TACE) for downstaging of the advanced HCCs. No further liver deterioration was observed after TACE, and HCC staging was successfully downstaged to within the Milan criteria. One hundred ten days after TACE, he underwent liver transplantation; at 2.5 years after transplantation, he remains alive without HCC recurrence.", + "summary_subclaims": [ + "A man in his 50s was diagnosed as having two foci of HCC.", + "The man had advanced liver cirrhosis.", + "Both foci of HCC were located in segment 8 of the liver.", + "The two foci of HCC measured 39 and 9 mm.", + "Endoscopy showed esophageal varices that had a high risk of bleeding.", + "After endoscopic ligation of the esophageal varices, he underwent transcatheter arterial chemoembolization (TACE) for downstaging of the advanced HCCs.", + "No further liver deterioration was observed after TACE.", + "HCC staging was successfully downstaged to within the Milan criteria.", + "One hundred ten days after TACE, he underwent liver transplantation.", + "At 2.5 years after transplantation, he remains alive without HCC recurrence." + ] + }, + { + "id": "multiclinsum_test_2525_en.txt", + "fulltext": "A 39-year-old healthy woman with normal menstrual periods presented to the emergency department because of postoperative cardiac arrest after a hysteroscopic myomectomy with general anesthesia. Preoperative blood tests revealed no anomalies. According to the local health facility, she had been irrigated with 8000 mL of 5% dextrose water with monopolar electrosurgery and subsequently underwent 35 min of cardiopulmonary resuscitation with medication including sodium bicarbonate 266 mmol (16 ampules) and other inotropic agents. On admission, her body weight was 74 kg (compared to presurgery body weight 62 kg); body mass index of 26.2; equal and dilated pupils; Glasgow coma scale of E1VTM1; low body temperature (32.9 °C), rapid heart rate (117 bpm), hypotension (74/47 mmHg), desaturation with SpO2 of 86% and less than 100% FiO2 support after intubation, and she was placed on ventilator support with a lung-protective strategy. Her laboratory tests revealed iso-osmotic hyponatremia, severe metabolic acidosis with hypercapnia and hypoxemia, hypoalbuminemia, and hemolysis with disseminated intravascular coagulopathy. The patient received a significant amount of sodium bicarbonate, so the acidosis was most likely much more severe at presentation and the acidosis may have been due to lactic acidosis. .\nThe patient was immediately resuscitated with 300 mL of intravenous 3% sodium chloride within 4 h for acute hyponatremia. Because of altered consciousness, mannitol and furosemide were administered for suspected brain edema. Inotropic agents and vasopressors were administered for profound shock status. Initial chest X-ray and chest CT were compatible with acute pulmonary edema . Echocardiogram revealed severe hypokinesia of the left ventricular apex with ejection fraction of 35%.Although initial troponin level was 1.944 ng/mL, subsequently, the levels increased to 18.46 and 20.73 ng/mL. After resuscitation, serum sodium level increased from 125 mmol/L to 139 mmol/L 3 h after admission and was 141 mmol/L 7 h after admission; however, the patient remained comatose. Brain CT 1 day after admission revealed no evidence of focal swelling. Subsequently, she was treated with CVVH to remove accumulated fluid from acute pulmonary edema and anuric acute kidney injury, which occurred despite the use of diuretics. Because of acute respiratory distress syndrome with severe hypercapnia, hypoxemia, and poor motion of the heart wall, the patient received venous–arterial ECMO. Further follow-up laboratory examinations revealed unremarkable thyroid function and adrenal function . As follow-up echocardiography revealed improved left ventricular diastolic and systolic function with ejection fraction of 57%, the patient was successfully weaned off ECMO on the day 9; she regained consciousness on day 10 and was successfully extubated on the day 13 of admission . She was relocated to the ward on postoperative day 25 and was released from the hospital on postoperative day 28 without any detectable sequelae.", + "fulltext_subclaims": [ + "A 39-year-old healthy woman with normal menstrual periods presented to the emergency department because of postoperative cardiac arrest after a hysteroscopic myomectomy with general anesthesia.", + "Preoperative blood tests revealed no anomalies.", + "According to the local health facility, she had been irrigated with 8000 mL of 5% dextrose water with monopolar electrosurgery.", + "She subsequently underwent 35 min of cardiopulmonary resuscitation with medication including sodium bicarbonate 266 mmol (16 ampules) and other inotropic agents.", + "On admission, her body weight was 74 kg.", + "On admission, her body mass index was 26.2.", + "On admission, her pupils were equal and dilated.", + "On admission, her Glasgow coma scale was E1VTM1.", + "On admission, her body temperature was 32.9 °C.", + "On admission, her heart rate was 117 bpm.", + "On admission, her blood pressure was 74/47 mmHg.", + "On admission, her SpO2 was 86%.", + "On admission, she was placed on ventilator support with a lung-protective strategy.", + "Her laboratory tests revealed iso-osmotic hyponatremia.", + "Her laboratory tests revealed severe metabolic acidosis with hypercapnia and hypoxemia.", + "Her laboratory tests revealed hypoalbuminemia.", + "Her laboratory tests revealed hemolysis with disseminated intravascular coagulopathy.", + "The patient received a significant amount of sodium bicarbonate.", + "The acidosis was most likely much more severe at presentation.", + "The acidosis may have been due to lactic acidosis.", + "The patient was immediately resuscitated with 300 mL of intravenous 3% sodium chloride within 4 h for acute hyponatremia.", + "Mannitol and furosemide were administered for suspected brain edema.", + "Inotropic agents and vasopressors were administered for profound shock status.", + "Initial chest X-ray was compatible with acute pulmonary edema.", + "Initial chest CT was compatible with acute pulmonary edema.", + "Echocardiogram revealed severe hypokinesia of the left ventricular apex with ejection fraction of 35%.", + "Initial troponin level was 1.944 ng/mL.", + "Subsequently, troponin levels increased to 18.46 and 20.73 ng/mL.", + "Serum sodium level increased from 125 mmol/L to 139 mmol/L 3 h after admission.", + "Serum sodium level was 141 mmol/L 7 h after admission.", + "The patient remained comatose.", + "Brain CT 1 day after admission revealed no evidence of focal swelling.", + "The patient was treated with CVVH to remove accumulated fluid from acute pulmonary edema.", + "The patient was treated with CVVH to remove accumulated fluid from anuric acute kidney injury.", + "The patient received venous–arterial ECMO.", + "Further follow-up laboratory examinations revealed unremarkable thyroid function.", + "Further follow-up laboratory examinations revealed unremarkable adrenal function.", + "Follow-up echocardiography revealed improved left ventricular diastolic and systolic function with ejection fraction of 57%.", + "The patient was successfully weaned off ECMO on the day 9.", + "The patient regained consciousness on day 10.", + "The patient was successfully extubated on the day 13 of admission.", + "The patient was relocated to the ward on postoperative day 25.", + "The patient was released from the hospital on postoperative day 28.", + "The patient had no detectable sequelae." + ], + "summary": "Herein we presented a 39-year-old female who presented with cardiac arrest after hysteroscopic myomectomy because of acute water intoxication and survived after extracorporeal membrane oxygenation, continuous venous-venous hemofiltration, and aggressive high sodium fluid resuscitation.", + "summary_subclaims": [ + "The patient was a 39-year-old female.", + "The patient presented with cardiac arrest after hysteroscopic myomectomy.", + "The cardiac arrest was due to acute water intoxication.", + "The patient survived after extracorporeal membrane oxygenation.", + "The patient received continuous venous-venous hemofiltration.", + "The patient received aggressive high sodium fluid resuscitation." + ] + }, + { + "id": "multiclinsum_test_2867_en.txt", + "fulltext": "A 40-year old female haemodialysis-dependent patient had a 2 year history of chronic refractory severe hypotension (≤80/50 mmHg). Previous treatment with α1-adrenergic agonist, mineralocorticoid analog and optimization of dialysate composition with sodium concentration >140 mmol/L and use of bicarbonate buffers had been non-effective. Aetiology of renal failure was reflux nephropathy. She had right native nephrectomy and left native pyeloplasty performed 21 years previously. She received a cadaveric renal graft 13 years ago which failed 9 years later because of chronic allograft nephropathy. The failed graft was removed 3 years previously due to recurrent sepsis. She had been anuric for the last 4 years. There was no history of diabetes, heart failure or ischemic heart disease. She had been on hemodialysis for 6 years following failed peritoneal dialysis. Dialysis adequacy during the 6 months prior to transplant was recorded with urea reduction rate of 75 % and Kt/V (measure of clearance per dialysis factored for patient size) of 1.6.\nComputed tomography scan revealed a grossly atrophic native left kidney. Transthoracic echocardiography showed normal valves, pericardium and ejection fraction was 62 %. Measures of central vascular stiffness were normal with carotid-femoral pulse wave velocity (PWV) of 5.9 m/s (reference range: 4.5–9.6 m/s) and augmentation index corrected to heart rate (AIx75) of 21 % (reference range: 19–24 %). Myocardial perfusion scan was normal. On maximal cardiopulmonary exercise testing (CPET) , oxygen consumption at peak exercise (VO2peak) was 18 ml/min/kg (73 % of predicted VO2peak) . Following 3 min rest, pedaling without load (freewheel stage of exercise) produced a 50 % increment in BP from baseline. An exaggerated rise in SBP and diastolic BP (DBP) was recorded at maximal work load, whereby BP rose from 82/50 mmHg to a peak of 201/120 mmHg (ΔSBP/ΔDBP = 119/70 mmHg). At this point, the patient abruptly ceased pedaling and a rapid decline in BP to baseline level was documented .\nThe patient proceeded to have an HLA antibody-incompatible kidney transplant. Immunosuppression consisted of mycophenolate mofetil, tacrolimus and prednisolone. A single dose of 500 mg methylprednisolone intra-operatively and basiliximab 20 mg were given at days 0 and 4. Pre-operatively she underwent seven sessions of HLA antibody removal therapy [, ] with cryofiltration, with a further two sessions (day 1 and 2) following surgery and one session of double filtration plasmapheresis on day 3. During the intraoperative period, her BP was supported by infusion of metaraminol. Post-operatively, she was vasopressor reliant for 14 days at which point the creatinine was 133 μmol/l (eGFR 41 ml/min/1.73 m2).\nEight weeks following transplantation, her resting BP without anti-hypertensive agent was 124/82 mmHg. Graft function was moderate with eGFR 39 ml/min/1.73 m2. On repeat CPET, SBP rose uniformly but DBP did not rise from baseline (ΔSBP/ΔDBP = 19/-13 mmHg) . VO2peak was comparable to the pre-transplant measure but there was improvement in the anaerobic threshold following transplant (VO2AT, 48 vs. 41 % of predicted VO2peak). Cortisol, renin and aldosterone levels at rest were (pre- vs. post-transplant) 433 vs. 356 nmol/l, <9 vs. 9 mU/l and 515 vs. 372 pmol/l, respectively .", + "fulltext_subclaims": [ + "The patient is a 40-year old female.", + "The patient is haemodialysis-dependent.", + "The patient had a 2 year history of chronic refractory severe hypotension.", + "The patient's blood pressure was ≤80/50 mmHg.", + "Previous treatment with α1-adrenergic agonist had been non-effective.", + "Previous treatment with mineralocorticoid analog had been non-effective.", + "Optimization of dialysate composition with sodium concentration >140 mmol/L had been non-effective.", + "The aetiology of renal failure was reflux nephropathy.", + "The patient had right native nephrectomy.", + "The patient had left native pyeloplasty.", + "The right native nephrectomy and left native pyeloplasty were performed 21 years previously.", + "The patient received a cadaveric renal graft 13 years ago.", + "The cadaveric renal graft failed 9 years later because of chronic allograft nephropathy.", + "The failed graft was removed 3 years previously due to recurrent sepsis.", + "The patient had been anuric for the last 4 years.", + "There was no history of diabetes.", + "There was no history of heart failure.", + "There was no history of ischemic heart disease.", + "The patient had been on hemodialysis for 6 years following failed peritoneal dialysis.", + "Dialysis adequacy during the 6 months prior to transplant was recorded with urea reduction rate of 75 %.", + "Dialysis adequacy during the 6 months prior to transplant was recorded with Kt/V of 1.6.", + "Computed tomography scan revealed a grossly atrophic native left kidney.", + "Transthoracic echocardiography showed normal valves.", + "Transthoracic echocardiography showed normal pericardium.", + "Ejection fraction was 62 %.", + "Carotid-femoral pulse wave velocity (PWV) was 5.9 m/s.", + "The reference range for carotid-femoral pulse wave velocity (PWV) is 4.5–9.6 m/s.", + "Augmentation index corrected to heart rate (AIx75) was 21 %.", + "The reference range for augmentation index corrected to heart rate (AIx75) is 19–24 %.", + "Myocardial perfusion scan was normal.", + "Oxygen consumption at peak exercise (VO2peak) was 18 ml/min/kg.", + "VO2peak was 73 % of predicted VO2peak.", + "Pedaling without load produced a 50 % increment in BP from baseline.", + "An exaggerated rise in SBP and diastolic BP (DBP) was recorded at maximal work load.", + "BP rose from 82/50 mmHg to a peak of 201/120 mmHg.", + "ΔSBP/ΔDBP was 119/70 mmHg.", + "The patient abruptly ceased pedaling.", + "A rapid decline in BP to baseline level was documented.", + "The patient proceeded to have an HLA antibody-incompatible kidney transplant.", + "Immunosuppression consisted of mycophenolate mofetil.", + "Immunosuppression consisted of tacrolimus.", + "Immunosuppression consisted of prednisolone.", + "A single dose of 500 mg methylprednisolone was given intra-operatively.", + "Basiliximab 20 mg was given at days 0 and 4.", + "The patient underwent seven sessions of HLA antibody removal therapy with cryofiltration pre-operatively.", + "The patient had two sessions of cryofiltration following surgery.", + "The patient had one session of double filtration plasmapheresis on day 3.", + "During the intraoperative period, her BP was supported by infusion of metaraminol.", + "Post-operatively, she was vasopressor reliant for 14 days.", + "At 14 days post-operatively, the creatinine was 133 μmol/l.", + "At 14 days post-operatively, the eGFR was 41 ml/min/1.73 m2.", + "Eight weeks following transplantation, her resting BP without anti-hypertensive agent was 124/82 mmHg.", + "Graft function was moderate with eGFR 39 ml/min/1.73 m2.", + "On repeat CPET, SBP rose uniformly but DBP did not rise from baseline.", + "ΔSBP/ΔDBP was 19/-13 mmHg.", + "VO2peak was comparable to the pre-transplant measure.", + "There was improvement in the anaerobic threshold following transplant.", + "VO2AT was 48 % of predicted VO2peak.", + "Cortisol levels were 433 nmol/l pre-transplant.", + "Cortisol levels were 356 nmol/l post-transplant.", + "Renin levels were <9 mU/l pre-transplant.", + "Renin levels were 9 mU/l post-transplant.", + "Aldosterone levels were 515 pmol/l pre-transplant.", + "Aldosterone levels were 372 pmol/l post-transplant." + ], + "summary": "A 40-year old haemodialysis-dependent patient with a 2 year history of refractory hypotension (≤80/50 mmHg) was referred for living donor renal transplantation at our tertiary centre. Each dialysis session was often less than 2 h and 30 min due to symptomatic hypotension. As part of the cardiovascular assessment, she underwent haemodynamic evaluation with cardiopulmonary exercise testing. Blood pressure normalized during unloaded pedalling but was exaggerated at maximal workload whereby it rose from 82/50 mmHg to a peak of 201/120 mmHg. Transthoracic echocardiography, tonometric measure of central vascular compliance and myocardial perfusion scan were normal. She subsequently underwent an antibody-incompatible renal transplantation and was vasopressor reliant for 14 days during the post-operative period. Eight weeks following transplant, resting blood pressure was normal and a physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing.", + "summary_subclaims": [ + "The patient is a 40-year old haemodialysis-dependent individual.", + "The patient has a 2 year history of refractory hypotension.", + "The patient's blood pressure is ≤80/50 mmHg.", + "The patient was referred for living donor renal transplantation.", + "Each dialysis session was often less than 2 h and 30 min.", + "The reason for short dialysis sessions was symptomatic hypotension.", + "The patient underwent haemodynamic evaluation with cardiopulmonary exercise testing.", + "Blood pressure normalized during unloaded pedalling.", + "Blood pressure rose from 82/50 mmHg to a peak of 201/120 mmHg at maximal workload.", + "Transthoracic echocardiography was normal.", + "Tonometric measure of central vascular compliance was normal.", + "Myocardial perfusion scan was normal.", + "The patient underwent an antibody-incompatible renal transplantation.", + "The patient was vasopressor reliant for 14 days during the post-operative period.", + "Eight weeks following transplant, resting blood pressure was normal.", + "A physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing." + ] + }, + { + "id": "multiclinsum_test_1076_en.txt", + "fulltext": "A 71-year-old female with a history of acid reflux presented to the emergency department following a syncopal episode, along with progressive diarrhea, weight loss, worsening jaundice, and fatigue. She had been undergoing outpatient evaluation for elevated liver enzymes over the past 2 years prior to admission. She was trialed on ursodiol and low-dose prednisone without much benefit prior to arrival.\nIn the emergency department, her vitals were remarkable for hypotension with a blood pressure of 72/53 mm Hg and a nadir HR of 62. Physical exam was significant for jaundice and cachexia. Blood work demonstrated leukocytosis 27.7 × 109/L (normal 3.4–9.6 × 109/L) with neutrophilic predominance. Hepatic function panel showed an aspartate transaminase level of 85 U/L (normal 8–43 U/L), alanine aminotransferase 85 U/L (normal 7–45 U/L), bilirubin 9.3 mg/dL (normal <1.2 mg/dL), and alkaline phosphatase of 2262 U/L (normal 35–104 U/L). Gamma-glutamyl transferase was elevated to 494 U/L (normal 5–36 U/L). C-reactive protein was 52 mg/L (normal <8 mg/L). TSH was elevated to 22.8 mL U/L (normal 0.3–4.2 mlU/L) with undetectable T3 and T4 levels. Review of a 6-month prior outside liver biopsy was consistent with periportal fibrosis with lymphocytic and scattered neutrophilic infiltrates in the portal tracts. No infiltrating histiocytes were noted in the biopsy.\nThe patient was admitted to the intensive care unit for vasodilatory shock, requiring vasopressors and chronotropic agents along with antibiotics. Computed tomography (CT) of the abdomen and pelvis with contrast illustrated diffusely heterogenous liver parenchymal enhancement without ductal dilatation, duodenitis, and diffuse colonic thickening concerning pancolitis (shown in a). CT chest was performed which showed centrilobular ground glass opacities bilaterally with mild pulmonary edema. Echocardiogram did not reveal any cardiac abnormality. Brain magnetic resonance imaging (MRI) with contrast revealed abnormal enhancement and thickening of the pituitary infundibulum and stalk most consistent with lymphocytic hypophysitis (shown in b).\nGiven the cholestatic nature of liver injury, magnetic resonance cholangiopancreatography was performed which showed multifocal nodular hepatic steatosis and hepatomegaly without any focal liver abnormality; in addition, multiple indeterminate bony lesions were read as non-specific focal sclerosis and cystic lesions. Autoantibody screening including anti-nuclear antibody, SS-A and SS-B antibodies, and anti-smooth muscle antibody were negative. IgG4 subclass levels were normal. A bone marrow biopsy showed 40% cellularity and reactive marrow changes without any blasts or infiltrate. Subcutaneous fat aspirate was negative for amyloid deposition on Congo red staining.\nThe patient was being optimized for a possible esophagogastroduodenoscopy and colonoscopy once more stable. A repeat liver biopsy revealed histiocytes infiltrating the biliary tree with chronic biliary tract injury. Tissue stained positive for CD1a and S100, markers of Langerhans cells, and BRAFV600E-mutated protein, commonly found in various malignancies (shown in ). No evidence of IgG4 sclerosing cholangitis was observed. A diagnosis of secondary sclerosing cholangitis and cirrhosis secondary to multisystem LCH was confirmed.\nTreatment was initiated with hydrocortisone and levothyroxine for panhypopituitarism. The patient was eventually started on dose reduced b-rapidly accelerator fibrosarcoma (BRAF) inhibitor, vemurafenib, after multidisciplinary discussion. The patient’s hospital course was also complicated by acute necrotizing pancreatitis, poorly controlled blood sugars, and new onset central diabetes insipidus that required treatment with desmopressin. Repeated hospitalizations in the following 3 months prompted her to opt for comfort care with palliative measures.", + "fulltext_subclaims": [ + "The patient is a 71-year-old female.", + "She has a history of acid reflux.", + "She presented to the emergency department following a syncopal episode.", + "She had progressive diarrhea.", + "She had weight loss.", + "She had worsening jaundice.", + "She had fatigue.", + "She had been undergoing outpatient evaluation for elevated liver enzymes over the past 2 years prior to admission.", + "She was trialed on ursodiol and low-dose prednisone without much benefit prior to arrival.", + "In the emergency department, her blood pressure was 72/53 mm Hg.", + "In the emergency department, her heart rate had a nadir of 62.", + "Physical exam was significant for jaundice.", + "Physical exam was significant for cachexia.", + "Blood work demonstrated leukocytosis 27.7 × 109/L.", + "Hepatic function panel showed an aspartate transaminase level of 85 U/L.", + "Hepatic function panel showed an alanine aminotransferase of 85 U/L.", + "Hepatic function panel showed a bilirubin of 9.3 mg/dL.", + "Hepatic function panel showed an alkaline phosphatase of 2262 U/L.", + "Gamma-glutamyl transferase was elevated to 494 U/L.", + "C-reactive protein was 52 mg/L.", + "TSH was elevated to 22.8 mL U/L.", + "T3 levels were undetectable.", + "T4 levels were undetectable.", + "A 6-month prior liver biopsy was consistent with periportal fibrosis.", + "The liver biopsy showed lymphocytic and scattered neutrophilic infiltrates in the portal tracts.", + "No infiltrating histiocytes were noted in the biopsy.", + "The patient was admitted to the intensive care unit.", + "The patient required vasopressors.", + "The patient required chronotropic agents.", + "The patient received antibiotics.", + "CT of the abdomen and pelvis showed diffusely heterogeneous liver parenchymal enhancement.", + "CT of the abdomen and pelvis showed duodenitis.", + "CT of the abdomen and pelvis showed diffuse colonic thickening concerning pancolitis.", + "CT chest showed centrilobular ground glass opacities bilaterally.", + "CT chest showed mild pulmonary edema.", + "Echocardiogram did not reveal any cardiac abnormality.", + "Brain MRI showed abnormal enhancement and thickening of the pituitary infundibulum and stalk.", + "Magnetic resonance cholangiopancreatography showed multifocal nodular hepatic steatosis.", + "Magnetic resonance cholangiopancreatography showed hepatomegaly.", + "Autoantibody screening including anti-nuclear antibody, SS-A and SS-B antibodies, and anti-smooth muscle antibody were negative.", + "IgG4 subclass levels were normal.", + "A bone marrow biopsy showed 40% cellularity.", + "A bone marrow biopsy showed reactive marrow changes.", + "A subcutaneous fat aspirate was negative for amyloid deposition on Congo red staining.", + "A repeat liver biopsy revealed histiocytes infiltrating the biliary tree.", + "Tissue stained positive for CD1a.", + "Tissue stained positive for S100.", + "Tissue stained positive for BRAFV600E-mutated protein.", + "No evidence of IgG4 sclerosing cholangitis was observed.", + "A diagnosis of secondary sclerosing cholangitis and cirrhosis secondary to multisystem LCH was confirmed.", + "Treatment was initiated with hydrocortisone for panhypopituitarism.", + "Treatment was initiated with levothyroxine for panhypopituitarism.", + "The patient was started on dose reduced BRAF inhibitor, vemurafenib, after multidisciplinary discussion.", + "The patient’s hospital course was complicated by acute necrotizing pancreatitis.", + "The patient had poorly controlled blood sugars.", + "The patient had new onset central diabetes insipidus.", + "The patient required treatment with desmopressin.", + "Repeated hospitalizations in the following 3 months prompted her to opt for comfort care with palliative measures." + ], + "summary": "We report a case of a 71-year-old female who presented with progressive weakness, weight loss, diarrhea, and jaundice, and had been undergoing outpatient workup for elevated liver enzymes for the last 2 years. She required admission to the intensive care unit for vasodilatory shock, requiring vasopressor and chronotropic support. Imaging showed an underlying multiorgan process involving the gastrointestinal tract, liver, spleen, and central nervous system. A repeat liver biopsy after a prior inconclusive one revealed the diagnosis of multisystem LCH presenting as secondary sclerosing cholangitis.", + "summary_subclaims": [ + "The patient was a 71-year-old female.", + "She presented with progressive weakness.", + "She had weight loss.", + "She had diarrhea.", + "She had jaundice.", + "She had been undergoing outpatient workup for elevated liver enzymes for the last 2 years.", + "She required admission to the intensive care unit.", + "She required vasopressor and chronotropic support.", + "Imaging showed an underlying multiorgan process.", + "The process involved the gastrointestinal tract.", + "The process involved the liver.", + "The process involved the spleen.", + "The process involved the central nervous system.", + "A repeat liver biopsy was performed.", + "A prior liver biopsy was inconclusive.", + "The repeat liver biopsy revealed the diagnosis of multisystem LCH.", + "The diagnosis was multisystem LCH presenting as secondary sclerosing cholangitis." + ] + }, + { + "id": "multiclinsum_test_321_en.txt", + "fulltext": "A 40-year-old man presented to the emergency department (ED) via emergency medical services following a high-speed motorcycle versus automobile collision. Due to respiratory distress and decreased breath sounds in the right lung field, needle decompression was performed on scene by paramedics. Upon arrival to the ED, the patient was hemodynamically stable with a heart rate of 89 beats per minute and blood pressure 120/74 millimeters of mercury (mm Hg). His mentation was intact. Physical exam revealed extensive right-sided chest wall ecchymosis and tenderness.\nPoint-of-care ultrasound (POCUS) demonstrated reduced lung sliding on the right and no intraperitoneal free fluid; however, cardiac windows were suboptimal and non-diagnostic. Bedside chest radiograph showed multiple right-sided rib fractures with apical and lateral pneumothorax. Computed tomography (CT) demonstrated fractures of right ribs 3–11 with accompanying pneumothorax, sternomanubrial joint dislocation with retrosternal hematoma, and pneumomediastinum . Additionally, the patient was found to have a grade 1 liver laceration and first lumbar (L1) vertebral body fracture with 10 mm of retropulsion.\nA 14-French pigtail catheter was placed into the right hemithorax without immediate complication. Twelve-lead electrocardiogram was remarkable for ST-segment elevation in leads aVR and aVL with diffuse ST depression in leads II, III, aVF, and V1–V6 concerning for BCI and prompting cardiology consultation . An initial high-sensitivity troponin T returned at 225 nanograms/milliliter (ng/mL) (reference range: <19). During the cardiology team’s evaluation, the patient complained of worsening chest pain and difficulty breathing, becoming hypotensive with a blood pressure of 78/59 mm Hg and tachycardic with a heart rate of 119 bpm.\nRepeat POCUS demonstrated bilateral lung sliding and no intra-abdominal free fluid; similarly, the chest tube and pleural drainage apparatus were functioning normally. Again, cardiac windows could not be obtained due to presumed air scattering. Because of significant pneumomediastinum seen on CT, obstructive shock physiology from the mediastinal free air was suspected. An emergent bedside percutaneous needle drainage in the left fifth intercostal space was performed, yielding 9 mL of blood with scant air bubbles. The patient’s blood pressure immediately improved, and cardiac windows were subsequently visualized on POCUS.\nWith high suspicion for acute myocardial infarction, the patient was taken for emergent coronary angiography. Transthoracic and transesophageal ultrasounds obtained in the cardiac catheterization lab did not demonstrate pericardial fluid or cardiac tamponade. Angiography demonstrated 95% thrombotic occlusion of the proximal left circumflex artery at the origin of the first obtuse marginal branch without evidence of coronary artery dissection . Percutaneous coronary intervention (PCI) with aspiration thrombectomy and deployment of two drug-eluting stents resulted in complete restoration of coronary blood flow. The patient was transferred to the surgical intensive care unit.\nAspirin and ticagrelor were initiated immediately after PCI. Norepinephrine and amiodarone were administered for cardiogenic shock and non-sustained ventricular tachycardia, respectively, both of which resolved within 48 hours. Following cardiac stabilization, the inpatient team addressed the patient’s spinal injury, although urgent operative intervention was deferred because of hemodynamic instability and the bleeding risk associated with antiplatelet therapy. Prior to spinal fixation on hospital day three, ticagrelor was changed to tirofiban infusion, which was held prior to the first incision and resumed postoperatively. Ticagrelor was re-started following the removal of a spinal drain on postoperative day two. The patient remained stable for the remainder of hospitalization and was discharged on aspirin and ticagrelor on hospital day 14.\nOn a follow-up phone call with the patient almost six months after the injury, he reported that he was back to working full time and feeling fully recovered. He recalled the accident and arriving to the ED, although he did not recall undergoing tube thoracostomy placement or percutaneous needle drainage. He was advised to continue aspirin and ticagrelor for at least six months.", + "fulltext_subclaims": [ + "A 40-year-old man presented to the emergency department via emergency medical services following a high-speed motorcycle versus automobile collision.", + "Needle decompression was performed on scene by paramedics.", + "Upon arrival to the ED, the patient was hemodynamically stable with a heart rate of 89 beats per minute and blood pressure 120/74 mm Hg.", + "Physical exam revealed extensive right-sided chest wall ecchymosis and tenderness.", + "Point-of-care ultrasound demonstrated reduced lung sliding on the right.", + "Bedside chest radiograph showed multiple right-sided rib fractures with apical and lateral pneumothorax.", + "Computed tomography demonstrated fractures of right ribs 3–11 with accompanying pneumothorax.", + "The patient was found to have a grade 1 liver laceration.", + "A 14-French pigtail catheter was placed into the right hemithorax.", + "Twelve-lead electrocardiogram was remarkable for ST-segment elevation in leads aVR and aVL.", + "An initial high-sensitivity troponin T returned at 225 ng/mL.", + "During the cardiology team’s evaluation, the patient became hypotensive with a blood pressure of 78/59 mm Hg.", + "Repeat POCUS demonstrated bilateral lung sliding.", + "Because of significant pneumomediastinum seen on CT, obstructive shock physiology from the mediastinal free air was suspected.", + "An emergent bedside percutaneous needle drainage in the left fifth intercostal space was performed.", + "The patient was taken for emergent coronary angiography.", + "Angiography demonstrated 95% thrombotic occlusion of the proximal left circumflex artery.", + "Percutaneous coronary intervention with aspiration thrombectomy and deployment of two drug-eluting stents resulted in complete restoration of coronary blood flow.", + "Aspirin and ticagrelor were initiated immediately after PCI.", + "Norepinephrine and amiodarone were administered.", + "Following cardiac stabilization, the inpatient team addressed the patient’s spinal injury.", + "Urgent operative intervention was deferred because of hemodynamic instability.", + "Ticagrelor was changed to tirofiban infusion prior to spinal fixation.", + "Ticagrelor was re-started following the removal of a spinal drain on postoperative day two.", + "The patient was discharged on aspirin and ticagrelor on hospital day 14.", + "On a follow-up phone call almost six months after the injury, he reported that he was back to working full time.", + "He recalled the accident and arriving to the ED.", + "He did not recall undergoing tube thoracostomy placement or percutaneous needle drainage.", + "He was advised to continue aspirin and ticagrelor for at least six months." + ], + "summary": "A 40-year-old man presented to the emergency department following a motorcycle accident. He was found to have multiple orthopedic injuries, pneumothorax, and pneumomediastinum. An electrocardiogram showed myocardial infarction. He developed obstructive shock physiology that resolved with mediastinal percutaneous needle drainage. Subsequent coronary angiography revealed acute thrombosis of the left circumflex artery.", + "summary_subclaims": [ + "The patient is a 40-year-old man.", + "He presented to the emergency department following a motorcycle accident.", + "He was found to have multiple orthopedic injuries.", + "He was found to have pneumothorax.", + "He was found to have pneumomediastinum.", + "An electrocardiogram showed myocardial infarction.", + "He developed obstructive shock physiology.", + "The obstructive shock physiology resolved with mediastinal percutaneous needle drainage.", + "Subsequent coronary angiography revealed acute thrombosis of the left circumflex artery." + ] + }, + { + "id": "multiclinsum_test_2235_en.txt", + "fulltext": "We presented the case of a 55-year-old man with left peripheral facial nerve palsy. The symptoms appeared one week earlier, along with viral upper respiratory infection.\nOtalgia started after two days accompanied by hearing loss and tinnitus on the left side; on the third day, vesiculoerosive lesions manifested itself in the left auricle , followed by the incidence of left side FNP .\nThe patient also suffered from true vertigo. On the same day of FNP incidence, the case developed hoarseness and fluid aspiration that became worse in the following days. The case had a surgery on the other ear (right side) 20 years earlier and 20 pack-year history of smoking. There were no diplopia, ptosis, headache, and the weakness of limbs or loss of consciousness. In addition, the patient had no history of diabetes or tuberculosis.\nThe physical examination revealed a left peripheral FNP grade VI based on House-Brackmann (HB) grading. In the right ear, he had previous surgical scar, along with central perforation with otorrhea. In the left ear, herpetic vesicles, as well as papules and pustules, associated with erythema and edema were observed in the ear canal and the conchal bowl . The laryngoscopic examination confirmed left vocal cord paralysis that was fixed in the paramedian position. The audiological evaluation verified left side profound hearing loss .\nThe patient was managed with RHS diagnosis associated with the paralysis of cranial nerves VIII and X, and the treatment started with acyclovir and prednisone 1mg⁄kg.\nThe FNP recovered after 2 weeks and the synkinesis totally improved following 4 weeks. Although fluid aspiration remarkably improved, left recurrent laryngeal nerve paralysis persisted on indirect laryngoscopy, with the compensation from opposite vocal cord. The case’s vertigo improved after 4 days of treatment; however, occasional non-pulsatile tinnitus still lingered on. The vesicles changed into scabs within 5 days and the inflammation and erythema disappeared after 2 to 3 weeks. The left side sensorineural hearing loss and also recurrent laryngeal nerve paralysis sustained for a year of follow-up.", + "fulltext_subclaims": [ + "The patient was a 55-year-old man.", + "He had left peripheral facial nerve palsy.", + "The symptoms appeared one week earlier.", + "The symptoms were associated with a viral upper respiratory infection.", + "Otalgia started after two days.", + "Hearing loss and tinnitus on the left side occurred.", + "Vesiculoerosive lesions manifested in the left auricle on the third day.", + "Left side facial nerve palsy (FNP) occurred.", + "The patient suffered from true vertigo.", + "Hoarseness and fluid aspiration developed on the same day as FNP incidence.", + "The patient had a surgery on the right ear 20 years earlier.", + "The patient had a 20 pack-year history of smoking.", + "There were no diplopia, ptosis, headache, limb weakness, or loss of consciousness.", + "The patient had no history of diabetes.", + "The patient had no history of tuberculosis.", + "Physical examination revealed left peripheral FNP grade VI based on House-Brackmann grading.", + "The right ear had a previous surgical scar.", + "The right ear had central perforation with otorrhea.", + "Herpetic vesicles, papules, and pustules were observed in the left ear canal and conchal bowl.", + "The laryngoscopic examination confirmed left vocal cord paralysis fixed in the paramedian position.", + "Audiological evaluation verified left side profound hearing loss.", + "The patient was managed with RHS diagnosis associated with cranial nerves VIII and X paralysis.", + "Treatment started with acyclovir and prednisone 1mg/kg.", + "Facial nerve palsy recovered after 2 weeks.", + "Synkinesis totally improved following 4 weeks.", + "Fluid aspiration remarkably improved.", + "Left recurrent laryngeal nerve paralysis persisted on indirect laryngoscopy.", + "Compensation from the opposite vocal cord occurred.", + "Vertigo improved after 4 days of treatment.", + "Occasional non-pulsatile tinnitus still lingered.", + "Vesicles changed into scabs within 5 days.", + "Inflammation and erythema disappeared after 2 to 3 weeks.", + "Left side sensorineural hearing loss and recurrent laryngeal nerve paralysis sustained for a year of follow-up." + ], + "summary": "Herein, we presented the case of a 55-year-old man with left peripheral facial nerve palsy, profound hearing loss, and true vocal cord paralysis. The FNP recovered after 2 weeks and synkinesis totally improved after 4 weeks.", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "The patient had left peripheral facial nerve palsy.", + "The patient had profound hearing loss.", + "The patient had true vocal cord paralysis.", + "The facial nerve palsy recovered after 2 weeks.", + "Synkinesis totally improved after 4 weeks." + ] + }, + { + "id": "multiclinsum_test_3119_en.txt", + "fulltext": "34-year-old black woman, from Equatorial Guinea, with a history of antiphospholipid syndrome and 6 pregnancies (1 miscarriage treated with curettage; 4 ectopic pregnancies, 2 of which were treated with methotrexate and 2 with salpingectomy). In the last pregnancy, an emergency cesarean section was performed due to vaginal bleeding in a full-term twin pregnancy with total occlusive placenta in a third-level public hospital. During the cesarean section, the patient presented postpartum hemorrhage secondary to uterine atony that did not respond to the administration of uterotonics, so the B-Lynch technique was performed, which is the most common uterine compression technique in the center where she was treated. The patient required admission to the intensive care unit, transfusion of two concentrates of red blood cells and was discharged, along with the neonates, on the fifth day after the cesarean section.\n\nOn the eighth day of puerperium, the patient went to the emergency room of the University Hospital of Getafe in Madrid, Spain, a public hospital of second level, different from the center where she was treated for the cesarean section. She reported continuous abdominal pain, predominantly in the hypogastrium, and micturition clinical (dysuria, pollakiuria and urinary urgency), without dysthermic sensation or gastrointestinal clinical.\n\nOn examination, the patient had a temperature of 36.7°C, blood pressure of 127/71 mm/Hg, heart rate of 89 bpm and oxygen saturation of 99%; on abdominal palpation, she reported pain in the hypogastrium with no signs of peritoneal irritation and a well contracted uterus. The surgical wound looked good, the lochia was normal, the cervix was permeable and she had no pain on cervical mobilization or clinical signs of post-cesarean endometritis. No adnexal masses were palpated.\n\nUrinalysis showed a white blood cell count of 500/uL, protein 100 mg/dL and 1774 white blood cells/field; in the blood count the white blood cells were 8960/uL, neutrophils 6320/uL, hemoglobin 9.4 g/dL, hematocrit 28.6%, platelets 390100/uL; in the biochemistry there was a C reactive protein of 40.3 mg/L. With these findings, the most probable diagnosis was a lower urinary tract infection, without ruling out other causes of abdominal pain, given the history of recent surgery. A transvaginal ultrasound showed an anteverted uterus with irregular endometrium of 2 mm with possible haematotic remains inside and with a heterogeneous formation at the level of the caesarean scar compatible with a haematoma of 66 x 18 x 81 mm. The ovaries were normal and there was no free abdominal-pelvic fluid.\n\nWith a diagnosis of lower urinary tract infection and a hematoma in the cesarean scar, admission of the patient for observation and treatment of the pain was decided. At 5 o'clock the analyses were repeated, which showed anaemia (haemoglobin 8.0 g/dL, haematocrit 24.1%). An abdominal ultrasound was performed, which showed a subjective increase in the size of the hematoma with respect to the previous ultrasound, so a revision in the operating theatre was decided.\n\nAn exploratory laparotomy (Pfannenstiel) was performed through the same incision of the cesarean scar. Necrosis of the hysterorrhaphy scar was observed, almost in its entirety, with dehiscence of the scar, mild lacerations in the serosa of the uterine body that coincided with the areas of compression of the suture and haematoma that extended to the vesical dome, so it was decided to perform a total hysterectomy. The ovaries were normal so they were preserved. Urology checked the integrity of the bladder by instilling methylene blue through the bladder catheter, although it was decided to keep the bladder catheter for a week with antibiotic prophylaxis.\n\nPostoperative evolution was favorable and the patient was discharged on the fourth postoperative day. She went to the gynecological emergency room for evaluation and removal of the bladder catheter on the seventh postoperative day. On the last follow-up visit, three months after surgery, the patient was well and was discharged.\n\nThe pathological anatomy report described extensive tissue necrosis at the level of the suture zone in the isthmus, with involvement of all uterine layers in a transmural manner, with multiple phenomena of thrombosis and vasculitis with fibrinoid necrosis.\n", + "fulltext_subclaims": [ + "The patient is a 34-year-old black woman from Equatorial Guinea.", + "She has a history of antiphospholipid syndrome.", + "She has had 6 pregnancies.", + "She had 1 miscarriage treated with curettage.", + "She had 4 ectopic pregnancies.", + "Two of the ectopic pregnancies were treated with methotrexate.", + "Two of the ectopic pregnancies were treated with salpingectomy.", + "In the last pregnancy, an emergency cesarean section was performed due to vaginal bleeding in a full-term twin pregnancy with total occlusive placenta.", + "The cesarean section was performed in a third-level public hospital.", + "During the cesarean section, the patient presented postpartum hemorrhage secondary to uterine atony.", + "The postpartum hemorrhage did not respond to the administration of uterotonics.", + "The B-Lynch technique was performed.", + "The B-Lynch technique is the most common uterine compression technique in the center where she was treated.", + "The patient required admission to the intensive care unit.", + "The patient received transfusion of two concentrates of red blood cells.", + "The patient was discharged on the fifth day after the cesarean section.", + "On the eighth day of puerperium, the patient went to the emergency room of the University Hospital of Getafe in Madrid, Spain.", + "The University Hospital of Getafe is a public hospital of second level.", + "The patient reported continuous abdominal pain, predominantly in the hypogastrium.", + "The patient reported micturition clinical symptoms: dysuria, pollakiuria, and urinary urgency.", + "The patient had a temperature of 36.7°C.", + "The patient had blood pressure of 127/71 mm/Hg.", + "The patient had a heart rate of 89 bpm.", + "The patient had oxygen saturation of 99%.", + "On abdominal palpation, the patient reported pain in the hypogastrium.", + "There were no signs of peritoneal irritation.", + "The surgical wound looked good.", + "The lochia was normal.", + "The cervix was permeable.", + "There was no pain on cervical mobilization.", + "There were no clinical signs of post-cesarean endometritis.", + "No adnexal masses were palpated.", + "Urinalysis showed a white blood cell count of 500/uL.", + "Urinalysis showed protein 100 mg/dL.", + "Urinalysis showed 1774 white blood cells/field.", + "The blood count showed white blood cells of 8960/uL.", + "The blood count showed neutrophils of 6320/uL.", + "The blood count showed hemoglobin 9.4 g/dL.", + "The blood count showed hematocrit 28.6%.", + "The blood count showed platelets 390100/uL.", + "The biochemistry showed C reactive protein of 40.3 mg/L.", + "The most probable diagnosis was a lower urinary tract infection.", + "A transvaginal ultrasound showed an anteverted uterus with irregular endometrium of 2 mm.", + "The transvaginal ultrasound showed possible haematotic remains inside the uterus.", + "The transvaginal ultrasound showed a heterogeneous formation at the level of the caesarean scar compatible with a haematoma of 66 x 18 x 81 mm.", + "The ovaries were normal.", + "There was no free abdominal-pelvic fluid.", + "With a diagnosis of lower urinary tract infection and a hematoma in the cesarean scar, admission of the patient for observation and treatment of the pain was decided.", + "At 5 o'clock, the analyses showed anaemia (haemoglobin 8.0 g/dL, haematocrit 24.1%).", + "An abdominal ultrasound showed a subjective increase in the size of the hematoma with respect to the previous ultrasound.", + "A revision in the operating theatre was decided.", + "An exploratory laparotomy (Pfannenstiel) was performed through the same incision of the cesarean scar.", + "Necrosis of the hysterorrhaphy scar was observed, almost in its entirety.", + "Dehiscence of the scar was observed.", + "Mild lacerations in the serosa of the uterine body were observed.", + "The lacerations coincided with the areas of compression of the suture.", + "A haematoma that extended to the vesical dome was observed.", + "It was decided to perform a total hysterectomy.", + "The ovaries were normal so they were preserved.", + "Urology checked the integrity of the bladder by instilling methylene blue through the bladder catheter.", + "It was decided to keep the bladder catheter for a week with antibiotic prophylaxis.", + "Postoperative evolution was favorable.", + "The patient was discharged on the fourth postoperative day.", + "She went to the gynecological emergency room for evaluation and removal of the bladder catheter on the seventh postoperative day.", + "On the last follow-up visit, three months after surgery, the patient was well.", + "The pathological anatomy report described extensive tissue necrosis at the level of the suture zone in the isthmus.", + "The tissue necrosis involved all uterine layers in a transmural manner.", + "Multiple phenomena of thrombosis and vasculitis with fibrinoid necrosis were observed." + ], + "summary": "A 34-year-old woman presented with abdominal pain on the eighth day after cesarean section for placenta previa, which required suturing of B-Lynch for uterine atony and whose diagnosis was uterine necrosis. The patient required total abdominal hysterectomy, with satisfactory evolution. A systematic search of the literature was performed in the Medline databases via Pubmed, Embase and Web of Science. Series and case reports and cohorts of women with uterine necrosis after the use of sutures of uterine compression for control of postpartum hemorrhage were searched. Sociodemographic and clinical variables were analyzed at diagnosis, suturing technique, diagnostic tests and treatment.\n", + "summary_subclaims": [ + "The patient was a 34-year-old woman.", + "She presented with abdominal pain on the eighth day after cesarean section.", + "The cesarean section was for placenta previa.", + "The patient required suturing of B-Lynch for uterine atony.", + "The diagnosis was uterine necrosis.", + "The patient required total abdominal hysterectomy.", + "The evolution after surgery was satisfactory.", + "A systematic search of the literature was performed in the Medline databases via Pubmed, Embase and Web of Science.", + "Series and case reports and cohorts of women with uterine necrosis after the use of sutures of uterine compression for control of postpartum hemorrhage were searched.", + "Sociodemographic and clinical variables were analyzed at diagnosis.", + "Suturing technique was analyzed.", + "Diagnostic tests were analyzed.", + "Treatment was analyzed." + ] + }, + { + "id": "multiclinsum_test_2781_en.txt", + "fulltext": "A 22-year-old patient who was 35 weeks pregnant was evaluated in the emergency department with a complaint of right-sided weakness. The COVID-19 polymerase chain reaction test was performed and was found to be positive. However, she did not have fever or respiratory distress and then was followed up at home without medication.\nThe patient started to have throbbing headaches that did not respond to analgesic treatment (paracetamol 1000 mg/day) for four days. The intensity of her headaches gradually increased, such that she was being awakened from sleep, and this condition was accompanied by nausea and vomiting.\nAfter this four-day period, she again felt weakness on her right side when she woke up in the morning. Twelve hours later, she went back to the emergency department because her weakness was increasing. At the emergency department, the patient was found to be normotensive, conscious, cooperative and oriented in a neurological examination. No fundus examination was performed, given that she was COVID-positive. Examinations on the patient’s visual field and vision showed normal results. Other cranial nerve examinations were normal. Her muscle strength ratio was 3/5 in the upper right extremity, 2/5 in the lower right extremity and 5/5 in the upper and lower left extremities. The foot sole skin reflex of the right lower extremity consisted of an extensor response. She presented decreased speech fluency and had difficulty in word finding, which were diagnosed as mild motor aphasia. Laboratory tests revealed high levels of fibrinogen (899 g/l; normal is 180-400) and D-dimer (6.38 mg/l; normal is 0-2). It was noted that the patient had also had high levels of fibrinogen (665 g/l) and D-dimer (2.2 mg/l) in examinations performed 10 days previously.\nDiffusion magnetic resonance imaging (MRI) showed cortical diffusion restriction in the left parietal region and a hypointense response in the apparent diffusion coefficient (ADC) . The result from the diffusion MRI was suggestive of venous sinus thrombosis. Widespread loss of flow in the superior sagittal sinus and right transverse sinus, suggesting partial venous thrombosis in the left transverse sinus, was observed in brain magnetic resonance imaging and magnetic resonance venous angiography . The brain MRI and magnetic resonance venography confirmed the diagnosis of venous sinus thrombosis. Thrombosis was not investigated in other parts of the body.\nThe polymerase chain reaction was repeated and the result was again positive. The patient was then hospitalized with the diagnoses of COVID-19 infection and venous sinus thrombosis. Other genetic, hematological and rheumatological examinations were planned, in order to investigate the etiology of her condition. Anticoagulant treatment (low molecular weight heparin) was started after the patient had been found to present a low platelet count (107,000/mm3), through evaluation of a peripheral blood smear.\nDiffuse contractions were observed in a non-stress test (NST), and tocolysis was started, consisting of nifedipine and betamethasone treatment. However, the patient’s labor could not be stopped after 18 hours of hospitalization. She was then admitted for an emergency cesarean section because the intracranial pressure was increasing. A healthy baby was delivered.\nSubsequently, the patient’s postpartum headache complaints decreased and her speech became fluent without any change in muscle strength deficit. Her thrombocyte counts decreased to 67,000/mm3. Anticoagulant therapy was continued, with peripheral smear follow-ups. Thoracic computed tomography was performed on the patient, who did not present respiratory distress, and the findings were compatible with COVID-19 pneumonia after birth . There was an increase in infection parameters, and the patient was started on hydroxychloroquine and ceftriaxone treatment.\nIn the examinations performed to ascertain risk factors, the patient was found to be positive for antinuclear antibodies (ANA) and showed prothrombin heterozygous mutation. The patient was negative for anti-cardiolipin antibodies and anti-double stranded DNA (dsDNA), and tests on lupus anticoagulant, homocysteine, protein C, protein S and antithrombin 3 showed results within normal limits.\nOn the third day following the birth, the patient’s headache complaint became completely resolved, her thrombocyte counts stopped decreasing and her thrombocytopenia improved over the subsequent days. The infection parameters regressed. Partial regression of the lesions was observed on control thoracic computed tomography. The patient’s general condition stabilized and she was discharged on the 10th day of hospitalization, with muscle strength 4-5/5 on the right side, which was mobilized without support. Continuation of low molecular weight heparin (LMWH) treatment was planned, along with neurological and hematological control tests at a polyclinic.", + "fulltext_subclaims": [ + "The patient was 35 weeks pregnant.", + "The patient had right-sided weakness.", + "The patient's COVID-19 polymerase chain reaction test was positive.", + "The patient did not have fever.", + "The patient did not have respiratory distress.", + "The patient was followed up at home without medication.", + "The patient had throbbing headaches.", + "The headaches did not respond to analgesic treatment (paracetamol 1000 mg/day).", + "The headaches lasted for four days.", + "The intensity of the headaches gradually increased.", + "The headaches were being awakened from sleep.", + "The headaches were accompanied by nausea and vomiting.", + "The patient again felt weakness on her right side when she woke up in the morning.", + "The patient went back to the emergency department because her weakness was increasing.", + "The patient was found to be normotensive.", + "The patient was conscious.", + "The patient was cooperative.", + "The patient was oriented in a neurological examination.", + "No fundus examination was performed.", + "The patient was diagnosed with mild motor aphasia.", + "The patient's fibrinogen level was 899 g/l.", + "The normal fibrinogen range is 180-400 g/l.", + "The patient's D-dimer level was 6.38 mg/l.", + "The normal D-dimer range is 0-2 mg/l.", + "The patient had previously had a fibrinogen level of 665 g/l.", + "The patient had previously had a D-dimer level of 2.2 mg/l.", + "Diffusion MRI showed cortical diffusion restriction in the left parietal region.", + "The diffusion MRI showed a hypointense response in the apparent diffusion coefficient.", + "The diffusion MRI result was suggestive of venous sinus thrombosis.", + "Widespread loss of flow in the superior sagittal sinus was observed.", + "Widespread loss of flow in the right transverse sinus was observed.", + "Partial venous thrombosis in the left transverse sinus was suggested.", + "The brain MRI and magnetic resonance venography confirmed the diagnosis of venous sinus thrombosis.", + "Thrombosis was not investigated in other parts of the body.", + "The patient was hospitalized with the diagnoses of COVID-19 infection and venous sinus thrombosis.", + "Anticoagulant treatment (low molecular weight heparin) was started.", + "The patient had a low platelet count (107,000/mm3).", + "Tocolysis was started, consisting of nifedipine and betamethasone treatment.", + "The patient's labor could not be stopped after 18 hours of hospitalization.", + "The patient was admitted for an emergency cesarean section.", + "A healthy baby was delivered.", + "The patient's postpartum headache complaints decreased.", + "The patient's speech became fluent.", + "The patient's thrombocyte counts decreased to 67,000/mm3.", + "Anticoagulant therapy was continued.", + "Thoracic computed tomography was performed.", + "The findings were compatible with COVID-19 pneumonia after birth.", + "There was an increase in infection parameters.", + "The patient was started on hydroxychloroquine and ceftriaxone treatment.", + "The patient was found to be positive for antinuclear antibodies (ANA).", + "The patient showed prothrombin heterozygous mutation.", + "The patient was negative for anti-cardiolipin antibodies.", + "The patient was negative for anti-double stranded DNA (dsDNA).", + "Tests on lupus anticoagulant showed results within normal limits.", + "Tests on homocysteine showed results within normal limits.", + "Tests on protein C showed results within normal limits.", + "Tests on protein S showed results within normal limits.", + "Tests on antithrombin 3 showed results within normal limits.", + "The patient's headache complaint became completely resolved on the third day following the birth.", + "The patient's thrombocyte counts stopped decreasing.", + "The patient's thrombocytopenia improved over the subsequent days.", + "The infection parameters regressed.", + "Partial regression of the lesions was observed on control thoracic computed tomography.", + "The patient was discharged on the 10th day of hospitalization.", + "The patient's muscle strength was 4-5/5 on the right side.", + "The patient was mobilized without support.", + "Continuation of low molecular weight heparin (LMWH) treatment was planned.", + "Neurological and hematological control tests were planned at a polyclinic." + ], + "summary": "We present the case of a pregnant woman who was diagnosed with venous sinus thrombosis after she developed headache and hemiparesis. Polymerase chain reaction (PCR) positivity lasted for two weeks after COVID-19 had been diagnosed.", + "summary_subclaims": [ + "The patient was diagnosed with venous sinus thrombosis.", + "The patient developed headache.", + "The patient developed hemiparesis.", + "Polymerase chain reaction (PCR) positivity lasted for two weeks.", + "The patient had been diagnosed with COVID-19." + ] + }, + { + "id": "multiclinsum_test_1535_en.txt", + "fulltext": "A 91-year-old Japanese woman with a past medical history of angina pectoris, hypertension and uterine carcinoma noted bilateral axillary pain and presented herself to an emergency room. As a physical examination and chest roentgenography showed no emergent findings and her pain improved, she returned home. However, she subsequently experienced several episodes of recurrent chest pain. At approximately 1 week after the onset, she was hospitalized due to continuous dyspnea and left chest pain. On examination, the patient was alert. Her body temperature was 36.4 °C, her pulse was 110 beats per minute, her blood pressure was 147/98 mmHg, and her respiratory rate was 28 breaths per minute. Her oxygen saturation was 98% on oxygen (6 L/min). A blood test revealed high levels of brain natriuretic peptide (BNP; 3431.5 pg/mL), creatine kinase (CK; 303 U/L), CK-MB (31 U/L), troponin T (0.813 ng/mL), C-reactive protein (CRP; 7.21 mg/dL), potassium (5.2 mEq/L), blood urea nitrogen (BUN; 41 mg/dL), creatinine (2.04 mg/dL), aspartate aminotransferase (AST; 68 U/L), and alanine aminotransferase (ALT; 35 U/L). Her red blood cell count was slightly low (3.61 × 106/μL). Her white blood cell count, platelet count, and sodium and chlorine levels were within the normal ranges. Electrocardiography revealed sinus rhythm, low voltage in limb and chest leads, and ST-segment elevation in leads II, III, aVF and V3 to V6. Echocardiography revealed medial to apical dyskinesia and basal hypercontractility of the left ventricle, which seemed to have a takotsubo-like shape , and cardiac tamponade. After the drainage of 400 mL of hemorrhagic pericardial effusion by pericardiocentesis, the patient’s symptoms improved; however, the cardiac dysfunction did not. Coronary angiography was not performed due to her age and low kidney function. At 3 days after her admission, cardiopulmonary resuscitation was performed for loss of consciousness due to ventricular fibrillation. The patient’s blood pressure, urine volume and consciousness level were decreased, and cyanosis, metabolic acidosis and hyperkalemia were subsequently emerged. She died on the 5th day of admission (2 weeks after the onset).\nThe patient was 137 cm tall, with a body weight of 34 kg; her BMI was 18. At autopsy, the heart weighed 360 g and had a takotsubo-like shape . The epicardium had a reddish color and rough surface. There were no findings of thrombus, embolism, obstruction or severe stenosis of the coronary arteries . There was no cardiac rupture. Remarkably, the left ventricle was dilated in the basal to middle segment, and the ventricular wall was thin, especially at the middle to apical segment . Serous pleural effusion (left 400 mL, right 600 mL) was present. The lower lobes of bilateral lung were collapsed (left 250 g, right 270 g). Bleeding of the intestinal mucosa and moderate atherosclerosis were seen. The liver, left kidney, right kidney and spleen weighed 560 g, 60 g, 70 g and 25 g respectively. Microscopically, the heart showed notable degeneration and necrosis. Wavy change and thinning of the myocardium were diffusely observed especially on the apex and anterior to lateral wall of the left ventricle, interventricular septum and right ventricle, intermingled with interstitial fibrosis, hemorrhage and neutrophil infiltration . Contraction band necrosis was mainly observed on the posterior to inferior wall of the left ventricle . The liver showed centrilobular necrosis. Ischemic change was seen on the intestinal mucosa, suggesting ischemic mucosal hemorrhage.", + "fulltext_subclaims": [ + "The patient was a 91-year-old Japanese woman.", + "She had a past medical history of angina pectoris.", + "She had a past medical history of hypertension.", + "She had a past medical history of uterine carcinoma.", + "She noted bilateral axillary pain.", + "She presented herself to an emergency room.", + "A physical examination showed no emergent findings.", + "Chest roentgenography showed no emergent findings.", + "Her pain improved.", + "She returned home.", + "She subsequently experienced several episodes of recurrent chest pain.", + "She was hospitalized due to continuous dyspnea.", + "She was hospitalized due to left chest pain.", + "On examination, the patient was alert.", + "Her body temperature was 36.4 °C.", + "Her pulse was 110 beats per minute.", + "Her blood pressure was 147/98 mmHg.", + "Her respiratory rate was 28 breaths per minute.", + "Her oxygen saturation was 98% on oxygen (6 L/min).", + "A blood test revealed high levels of brain natriuretic peptide (BNP; 3431.5 pg/mL).", + "A blood test revealed high levels of creatine kinase (CK; 303 U/L).", + "A blood test revealed high levels of CK-MB (31 U/L).", + "A blood test revealed high levels of troponin T (0.813 ng/mL).", + "A blood test revealed high levels of C-reactive protein (CRP; 7.21 mg/dL).", + "A blood test revealed high levels of potassium (5.2 mEq/L).", + "A blood test revealed high levels of blood urea nitrogen (BUN; 41 mg/dL).", + "A blood test revealed high levels of creatinine (2.04 mg/dL).", + "A blood test revealed high levels of aspartate aminotransferase (AST; 68 U/L).", + "A blood test revealed high levels of alanine aminotransferase (ALT; 35 U/L).", + "Her red blood cell count was slightly low (3.61 × 106/μL).", + "Her white blood cell count was within the normal range.", + "Her platelet count was within the normal range.", + "Her sodium levels were within the normal range.", + "Her chlorine levels were within the normal range.", + "Electrocardiography revealed sinus rhythm.", + "Electrocardiography revealed low voltage in limb and chest leads.", + "Electrocardiography revealed ST-segment elevation in leads II, III, aVF and V3 to V6.", + "Echocardiography revealed medial to apical dyskinesia of the left ventricle.", + "Echocardiography revealed basal hypercontractility of the left ventricle.", + "Echocardiography revealed a takotsubo-like shape.", + "Echocardiography revealed cardiac tamponade.", + "After the drainage of 400 mL of hemorrhagic pericardial effusion by pericardiocentesis, the patient’s symptoms improved.", + "The cardiac dysfunction did not improve.", + "Coronary angiography was not performed due to her age.", + "Coronary angiography was not performed due to her low kidney function.", + "At 3 days after her admission, cardiopulmonary resuscitation was performed for loss of consciousness due to ventricular fibrillation.", + "The patient’s blood pressure was decreased.", + "The patient’s urine volume was decreased.", + "The patient’s consciousness level was decreased.", + "Cyanosis emerged.", + "Metabolic acidosis emerged.", + "Hyperkalemia emerged.", + "She died on the 5th day of admission.", + "The patient’s height was 137 cm.", + "The patient’s body weight was 34 kg.", + "Her BMI was 18.", + "At autopsy, the heart weighed 360 g.", + "The heart had a takotsubo-like shape.", + "The epicardium had a reddish color.", + "The epicardium had a rough surface.", + "There were no findings of thrombus in the coronary arteries.", + "There were no findings of embolism in the coronary arteries.", + "There were no findings of obstruction in the coronary arteries.", + "There were no findings of severe stenosis in the coronary arteries.", + "There was no cardiac rupture.", + "The left ventricle was dilated in the basal to middle segment.", + "The ventricular wall was thin, especially at the middle to apical segment.", + "Serous pleural effusion (left 400 mL, right 600 mL) was present.", + "The lower lobes of bilateral lung were collapsed (left 250 g, right 270 g).", + "Bleeding of the intestinal mucosa was seen.", + "Moderate atherosclerosis was seen.", + "The liver weighed 560 g.", + "The left kidney weighed 60 g.", + "The right kidney weighed 70 g.", + "The spleen weighed 25 g.", + "Microscopically, the heart showed notable degeneration and necrosis.", + "Wavy change and thinning of the myocardium were diffusely observed especially on the apex and anterior to lateral wall of the left ventricle, interventricular septum and right ventricle.", + "Interstitial fibrosis was observed.", + "Hemorrhage was observed.", + "Neutrophil infiltration was observed.", + "Contraction band necrosis was mainly observed on the posterior to inferior wall of the left ventricle.", + "The liver showed centrilobular necrosis.", + "Ischemic change was seen on the intestinal mucosa.", + "Ischemic mucosal hemorrhage was suggested." + ], + "summary": "A 91-year-old Japanese woman with a past medical history of angina pectoris, hypertension and uterine carcinoma noted bilateral axillary pain and presented herself to an emergency room. Although the pain improved and she went home, there were several subsequent episodes of recurrent chest pain. At approximately 1 week after the onset, she was hospitalized as her symptom worsened. Electrocardiography showed low voltage in limb and chest leads, and ST-segment elevation in leads II, III, aVF and V3 to V6. Echocardiography revealed medial to apical dyskinesia and basal hypercontractility of the left ventricle, and cardiac tamponade. Pericardiocentesis improved the symptom, but not her cardiac dysfunction. At 3 days after her admission, cardiopulmonary resuscitation was performed due to ventricular fibrillation. She died on the 5th day of admission (2 weeks after the onset). At autopsy, the left ventricle was dilatated and the apical ventricular wall was thin. On microscopy, remarkable wavy change and thinning of myocardium were diffusely observed, especially at the apex and the anterior to lateral wall of the left ventricle, interventricular septum and right ventricle, intermingled with interstitial fibrosis, hemorrhage and neutrophil infiltration. Contraction band necrosis was mainly observed on the posterior to inferior wall of the left ventricle.", + "summary_subclaims": [ + "The patient was a 91-year-old Japanese woman.", + "She had a past medical history of angina pectoris.", + "She had a past medical history of hypertension.", + "She had a past medical history of uterine carcinoma.", + "She noted bilateral axillary pain.", + "She presented herself to an emergency room.", + "The pain improved and she went home.", + "There were several subsequent episodes of recurrent chest pain.", + "She was hospitalized approximately 1 week after the onset.", + "Electrocardiography showed low voltage in limb and chest leads.", + "Electrocardiography showed ST-segment elevation in leads II, III, aVF and V3 to V6.", + "Echocardiography revealed medial to apical dyskinesia of the left ventricle.", + "Echocardiography revealed basal hypercontractility of the left ventricle.", + "Echocardiography revealed cardiac tamponade.", + "Pericardiocentesis improved the symptom.", + "Pericardiocentesis did not improve her cardiac dysfunction.", + "Cardiopulmonary resuscitation was performed due to ventricular fibrillation.", + "She died on the 5th day of admission.", + "The left ventricle was dilatated at autopsy.", + "The apical ventricular wall was thin at autopsy.", + "Microscopy showed remarkable wavy change and thinning of myocardium.", + "Wavy change and thinning were observed especially at the apex and the anterior to lateral wall of the left ventricle.", + "Wavy change and thinning were observed on the interventricular septum.", + "Wavy change and thinning were observed on the right ventricle.", + "Interstitial fibrosis was observed.", + "Hemorrhage was observed.", + "Neutrophil infiltration was observed.", + "Contraction band necrosis was mainly observed on the posterior to inferior wall of the left ventricle." + ] + }, + { + "id": "multiclinsum_test_1600_en.txt", + "fulltext": "A 55-year-old male applied to our clinic with a sudden pain in his right shoulder, 2 years after a reverse total shoulder arthroplasty (RTSA) in another hospital due to rotator cuff arthropathy. He was a gardener and returned to his work after 2 months of the operation. His range of motion (ROM) was improved and had no pain in his daily activities after several months. However, almost 2 years from the initial surgery, he suddenly felt extreme pain in his shoulder when he tried to operate a vacuum cleaner. He applied to our clinic after trying painkillers for 3 weeks. A sharp pain in the shoulder, restrained ROM, and a loosening-like feeling were his major complaints at his admission with a normal neurovascular examination and without any comorbidities. Plain radiographs of his shoulder were taken and a RTSA with a broken humeral stem was determined . Further evaluation was done with a computed tomography of the right shoulder to evaluate any occult fracture around the shoulder girdle and bony fracture was excluded from the study.\nA one-stage operation was planned for revision. We used the previous incision line for the deltopectoral approach. After reaching the glenohumeral joint, the prosthesis was found to be dislocated and broken at the humeral tray of proximal stem. The model itself was a modular stem and due to the suspicion of infection, samples were taken from the surrounding synovium and joint fluid. Metallosis and debris tissue were debrided. The humeral stem and the glenoid hemisphere were removed with its cement and a cemented long humeral stem (SMR, Lima LTO, Udine, Italy) was placed . The glenohumeral joint was then reduced and the layers were anatomically closed. No post-operative complications were spotted. The synovial culture which had been taken for the suspicion of an infection was reported sterile. A frozen section analysis revealed active chronic synovitis, fibrosis, and giant cell reaction of foreign bodies. Shoulder physiotherapy with ROM and strengthening exercises were applied to the patient for 3-month postoperatively. No complication has occurred during his 3-year follow-up after surgery and the patient has nearly full ROM with only 20° of loss in abduction and has neither pain nor complaints. The patient was satisfied with result of the treatment and gained full function of his right shoulder.", + "fulltext_subclaims": [ + "A 55-year-old male applied to our clinic with a sudden pain in his right shoulder.", + "He had a reverse total shoulder arthroplasty (RTSA) in another hospital 2 years prior.", + "The RTSA was performed due to rotator cuff arthropathy.", + "He returned to work as a gardener after 2 months of the operation.", + "His range of motion was improved and he had no pain in daily activities after several months.", + "Almost 2 years after the initial surgery, he suddenly felt extreme pain in his shoulder when operating a vacuum cleaner.", + "He applied to our clinic after trying painkillers for 3 weeks.", + "His major complaints at admission were sharp pain in the shoulder, restrained ROM, and a loosening-like feeling.", + "Plain radiographs showed a broken humeral stem.", + "A computed tomography of the right shoulder was done to evaluate any occult fracture.", + "Bony fracture was excluded from the computed tomography study.", + "A one-stage operation was planned for revision.", + "The previous incision line was used for the deltopectoral approach.", + "The prosthesis was found to be dislocated and broken at the humeral tray of the proximal stem.", + "The model was a modular stem.", + "Samples were taken from the surrounding synovium and joint fluid due to suspicion of infection.", + "Metallosis and debris tissue were debrided.", + "The humeral stem and the glenoid hemisphere were removed with their cement.", + "A cemented long humeral stem (SMR, Lima LTO, Udine, Italy) was placed.", + "The glenohumeral joint was reduced and the layers were anatomically closed.", + "No post-operative complications were spotted.", + "The synovial culture was reported sterile.", + "A frozen section analysis revealed active chronic synovitis, fibrosis, and giant cell reaction of foreign bodies.", + "Shoulder physiotherapy with ROM and strengthening exercises were applied for 3 months postoperatively.", + "No complication has occurred during his 3-year follow-up after surgery.", + "The patient has nearly full ROM with only 20° of loss in abduction.", + "The patient has neither pain nor complaints.", + "The patient was satisfied with the result of the treatment.", + "The patient gained full function of his right shoulder." + ], + "summary": "A 55-year-old male patient was admitted to our hospital with a sharp pain after 2 years of his initial reverse total shoulder arthroplasty (RTSA) surgery. A broken humeral stem of the RTSA was diagnosed on the plain radiography and the patient underwent a one-stage revision. Further complications have not arisen during his follow-up to date and the patient has a nearly full range of motion.", + "summary_subclaims": [ + "A 55-year-old male patient was admitted to our hospital with a sharp pain after 2 years of his initial reverse total shoulder arthroplasty (RTSA) surgery.", + "A broken humeral stem of the RTSA was diagnosed on the plain radiography.", + "The patient underwent a one-stage revision.", + "Further complications have not arisen during his follow-up to date.", + "The patient has a nearly full range of motion." + ] + }, + { + "id": "multiclinsum_test_391_en.txt", + "fulltext": "A 35 years old man was hospitalised for multiple, painful and debilitating ulcers over both lower limb and scrotum. It initially started as a small wound over his right shin which gradually grew in size. Subsequently multiple similar lesions appeared extensively on both lower limb and scrotum over a period of 5 months. He was treated with multiple courses of antibiotics to no avail.\nAdditionally, he had 6 months history of polyarthralgia involving the inter-phalangeal joints of both hands, knees and elbows. He reported early morning stiffness of both hands with discolouration and numbness of his fingers upon exposure to cold temperatures. He also complained of bilateral lower limb numbness. He had significant impairment to his activities of daily living as a consequence of these symptoms. Besides that, he also complained of dysphagia, unintentional weight loss of 10 kg and fatigue.\nThere was no fever, recurrent oral ulcers, photosensitivity rash and history of gritty or red eyes. He denied chronic cough or night sweats. He had no abdominal pain or alteration in bowel habits. Review of other systems were unremarkable. Family and past medical history were insignificant. He denied alcohol intake, smoking, or use of recreational drugs. He was not a vegetarian and consumed meat regularly. There was no known food intolerance, medication allergies and surgical history.\nOn examination, the patient was afebrile and normotensive with a pulse rate of 110 bpm. There was clear evidence of alopecia, generalised hyper-pigmented fragile skin, depapillation of tongue and bilateral parotid swelling. Raynaud’s phenomenon was noted over both hands. Multiple tiny lymph nodes were palpable over bilateral cervical and supraclavicular areas which were soft and mobile. There were multiple ulcers on his scrotum and both legs of varying ages indicating chronicity with the largest measuring 10 × 5 cm. The ulcers were irregular in shape, had erythematous-purplish borders with a yellowish necrotic base. However, the legs were warm and well perfused, with distinctly palpable peripheral pulses. There was no nodular lesions or thrombophlebitis over the lower extremities. Neurological examination of his lower limbs revealed symmetrical paraesthesia distally with loss of vibratory sensation and diminished proprioception. Respiratory, cardiovascular and abdominal examinations were normal .\nLaboratory investigations revealed haemoglobin of 8 g/dl, mean corpuscular volume (MCV) of 84 fL, white blood cells of 6.27 × 10^3/μL with a lymphocyte count of 1.02 × 10^3 /μL. A peripheral blood film showed normochromic, normocytic anaemia with no evidence of haemolysis or abnormal blast cells. Anaemic work up showed low serum iron of 3.7 μmol/L, total iron binding capacity value of 25.3 μmol/L, low transferrin saturation of 14.6%, serum ferritin of 100 ng/ml, low cobalamin level of 176 pg/mL and normal folate level of 16.3 pg/mL. Serum cortisol level was low at 124.6 nmol/L whilst sodium and potassium levels were also low at 130 mmol/L and 3.0 mmol/L respectively. Liver function test showed low albumin level at 27 g/L with slightly raised AST at 63 U/L. Renal profile and coagulation screening were normal. Antinuclear antibody (ANA) was positive at a titre of 1:5120 which has a speckled pattern. Other autoimmune screening showed positive anti-SSA/Ro 60, anti-SSA/Ro 52, antiSmD1, and anti U1-snRNP. C-ANCA, p-ANCA, double stranded DNA, anti-SSB/La and rheumatoid factor were not detected. Complement 3 and 4 were below the reference range. Both inflammatory markers were elevated with CRP of 219 mg/L and ESR of 154 mm/hr. Serum protein electrophoresis displayed no paraprotein band or immunoparesis. Quantitative serum immunoglobulin test were normal. The serological tests for various infectious agents (HBsAg, anti HCV ab, anti HIV 1 + 2 ab and treponemal tests) were negative. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were below detection limits.\nCultures and sensitivities from the leg ulcers were positive for Proteus mirabilis. He was treated with a two-week course of intravenous amoxicillin/clavulanic acid. Histopathological examination of the leg ulcers demonstrated dense inflammatory cells infiltrate with neutrophil predominance. There was no evidence of necrotising vasculitis, vascular thrombosis, squamous dysplasia or invasive malignancy. No atypical mycobacteria or yeast were detected. An oesophagogastroduodenoscopy and colonoscopy was done which revealed atrophic gastritis, duodenitis and normal colonic mucosa. Campylobacter-like organism (CLO) test was negative. Histologically, the biopsies of small bowel showed well-formed and irregularly spaced glands secondary to expansion of lamina propria by lymphoplasmacytic inflammatory cell infiltrates. Colonic biopsies were insignificant. Periodic acid-Schiff (PAS) staining was negative. The findings were inconsistent with inflammatory bowel disease, Whipple’s disease, coeliac disease or pernicious anaemia.\nBased on clinical features, laboratory investigations, endoscopic and histological findings, he was diagnosed as SLE with pyoderma gangrenosum and cobalamin deficiency. He was treated with prednisolone, hydroxychloroquine, methotrexate, parenteral cyanocobalamin and iron supplements. Noticeable clinical improvement was observed after commencement of recommended treatment. Upon clinic review 1 month later, he reported weight gain, increased level of well-being, great improvement of skin lesions along with significant control of symptoms.", + "fulltext_subclaims": [ + "A 35 years old man was hospitalised for multiple, painful and debilitating ulcers over both lower limb and scrotum.", + "It initially started as a small wound over his right shin which gradually grew in size.", + "Subsequently multiple similar lesions appeared extensively on both lower limb and scrotum over a period of 5 months.", + "He was treated with multiple courses of antibiotics to no avail.", + "He had 6 months history of polyarthralgia involving the inter-phalangeal joints of both hands, knees and elbows.", + "He reported early morning stiffness of both hands with discolouration and numbness of his fingers upon exposure to cold temperatures.", + "He also complained of bilateral lower limb numbness.", + "He had significant impairment to his activities of daily living as a consequence of these symptoms.", + "He also complained of dysphagia, unintentional weight loss of 10 kg and fatigue.", + "There was no fever, recurrent oral ulcers, photosensitivity rash and history of gritty or red eyes.", + "He denied chronic cough or night sweats.", + "He had no abdominal pain or alteration in bowel habits.", + "Review of other systems were unremarkable.", + "Family and past medical history were insignificant.", + "He denied alcohol intake, smoking, or use of recreational drugs.", + "He was not a vegetarian and consumed meat regularly.", + "There was no known food intolerance, medication allergies and surgical history.", + "On examination, the patient was afebrile and normotensive with a pulse rate of 110 bpm.", + "There was clear evidence of alopecia, generalised hyper-pigmented fragile skin, depapillation of tongue and bilateral parotid swelling.", + "Raynaud’s phenomenon was noted over both hands.", + "Multiple tiny lymph nodes were palpable over bilateral cervical and supraclavicular areas which were soft and mobile.", + "There were multiple ulcers on his scrotum and both legs of varying ages indicating chronicity with the largest measuring 10 × 5 cm.", + "The ulcers were irregular in shape, had erythematous-purplish borders with a yellowish necrotic base.", + "However, the legs were warm and well perfused, with distinctly palpable peripheral pulses.", + "There was no nodular lesions or thrombophlebitis over the lower extremities.", + "Neurological examination of his lower limbs revealed symmetrical paraesthesia distally with loss of vibratory sensation and diminished proprioception.", + "Respiratory, cardiovascular and abdominal examinations were normal.", + "Laboratory investigations revealed haemoglobin of 8 g/dl, mean corpuscular volume (MCV) of 84 fL, white blood cells of 6.27 × 10^3/μL with a lymphocyte count of 1.02 × 10^3 /μL.", + "A peripheral blood film showed normochromic, normocytic anaemia with no evidence of haemolysis or abnormal blast cells.", + "Anaemic work up showed low serum iron of 3.7 μmol/L, total iron binding capacity value of 25.3 μmol/L, low transferrin saturation of 14.6%, serum ferritin of 100 ng/ml, low cobalamin level of 176 pg/mL and normal folate level of 16.3 pg/mL.", + "Serum cortisol level was low at 124.6 nmol/L whilst sodium and potassium levels were also low at 130 mmol/L and 3.0 mmol/L respectively.", + "Liver function test showed low albumin level at 27 g/L with slightly raised AST at 63 U/L.", + "Renal profile and coagulation screening were normal.", + "Antinuclear antibody (ANA) was positive at a titre of 1:5120 which has a speckled pattern.", + "Other autoimmune screening showed positive anti-SSA/Ro 60, anti-SSA/Ro 52, antiSmD1, and anti U1-snRNP.", + "C-ANCA, p-ANCA, double stranded DNA, anti-SSB/La and rheumatoid factor were not detected.", + "Complement 3 and 4 were below the reference range.", + "Both inflammatory markers were elevated with CRP of 219 mg/L and ESR of 154 mm/hr.", + "Serum protein electrophoresis displayed no paraprotein band or immunoparesis.", + "Quantitative serum immunoglobulin test were normal.", + "The serological tests for various infectious agents (HBsAg, anti HCV ab, anti HIV 1 + 2 ab and treponemal tests) were negative.", + "Intrinsic factor antibodies and anti-tissue transglutaminase IgA were below detection limits.", + "Cultures and sensitivities from the leg ulcers were positive for Proteus mirabilis.", + "He was treated with a two-week course of intravenous amoxicillin/clavulanic acid.", + "Histopathological examination of the leg ulcers demonstrated dense inflammatory cells infiltrate with neutrophil predominance.", + "There was no evidence of necrotising vasculitis, vascular thrombosis, squamous dysplasia or invasive malignancy.", + "No atypical mycobacteria or yeast were detected.", + "An oesophagogastroduodenoscopy and colonoscopy was done which revealed atrophic gastritis, duodenitis and normal colonic mucosa.", + "Campylobacter-like organism (CLO) test was negative.", + "Histologically, the biopsies of small bowel showed well-formed and irregularly spaced glands secondary to expansion of lamina propria by lymphoplasmacytic inflammatory cell infiltrates.", + "Colonic biopsies were insignificant.", + "Periodic acid-Schiff (PAS) staining was negative.", + "The findings were inconsistent with inflammatory bowel disease, Whipple’s disease, coeliac disease or pernicious anaemia.", + "Based on clinical features, laboratory investigations, endoscopic and histological findings, he was diagnosed as SLE with pyoderma gangrenosum and cobalamin deficiency.", + "He was treated with prednisolone, hydroxychloroquine, methotrexate, parenteral cyanocobalamin and iron supplements.", + "Noticeable clinical improvement was observed after commencement of recommended treatment.", + "Upon clinic review 1 month later, he reported weight gain, increased level of well-being, great improvement of skin lesions along with significant control of symptoms." + ], + "summary": "A 35 years old man presented with a 5 month history of debilitating painful lower limb and scrotal ulcers. This was associated with polyarthralgia and morning stiffness involving both hands. He also complained of swallowing difficulties. He had unintentional weight loss of 10 kg and fatigue. Physical examination revealed alopecia, multiple cervical lymphadenopathies, bilateral parotid gland enlargement and atrophic glossitis. There was Raynaud's phenomenon noted over both hands and generalised hyper-pigmented fragile skin. Laboratory results disclosed anaemia, leukopenia, hyponatraemia and hypocortisolism. Detailed anaemic workup revealed low serum ferritin and cobalamin level. The autoimmune screen showed positive ANA, anti SmD1, anti SS-A/Ro 52, anti SSA/Ro 60, anti U1-snRNP with low complement levels. Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis and duodenitis. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were all negative. Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum. Based on the clinical findings and positive immunologic studies, he was diagnosed as systemic lupus erythematosus. His general condition improved substantially with commencement of corticosteroids, immunosuppressants and vitamin supplements.", + "summary_subclaims": [ + "The patient is a 35 years old man.", + "The patient had a 5 month history of debilitating painful lower limb and scrotal ulcers.", + "The patient had polyarthralgia and morning stiffness involving both hands.", + "The patient had swallowing difficulties.", + "The patient had unintentional weight loss of 10 kg.", + "Physical examination revealed alopecia.", + "Physical examination revealed multiple cervical lymphadenopathies.", + "Physical examination revealed bilateral parotid gland enlargement.", + "Physical examination revealed atrophic glossitis.", + "There was Raynaud's phenomenon noted over both hands.", + "There was generalised hyper-pigmented fragile skin.", + "Laboratory results disclosed anaemia.", + "Laboratory results disclosed leukopenia.", + "Laboratory results disclosed hyponatraemia.", + "Laboratory results disclosed hypocortisolism.", + "Detailed anaemic workup revealed low serum ferritin.", + "Detailed anaemic workup revealed low cobalamin level.", + "The autoimmune screen showed positive ANA.", + "The autoimmune screen showed positive anti SmD1.", + "The autoimmune screen showed positive anti SS-A/Ro 52.", + "The autoimmune screen showed positive anti SSA/Ro 60.", + "The autoimmune screen showed positive anti U1-snRNP.", + "The autoimmune screen showed low complement levels.", + "Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis.", + "Upper gastrointestinal endoscopy with biopsies confirmed duodenitis.", + "Intrinsic factor antibodies were negative.", + "Anti-tissue transglutaminase IgA was negative.", + "Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum.", + "He was diagnosed as systemic lupus erythematosus.", + "His general condition improved substantially with commencement of corticosteroids.", + "His general condition improved substantially with commencement of immunosuppressants.", + "His general condition improved substantially with commencement of vitamin supplements." + ] + }, + { + "id": "multiclinsum_test_1426_en.txt", + "fulltext": "This case report describes to a Brazilian woman, 42 years-old, who presented with a renal failure and was submitted to haemodialysis for five years, before a kidney transplant, which occurred in 2007. After transplantation, the therapeutic regimen of immunosuppression included prednisone (5 mg daily), tacrolimus (5 mg daily) and azathioprine (50 mg daily). Dosage of serum tacrolimus was 5.8 ng/mL.\nThe donor’s B19 status for this recipient was unknown. In December 2010, the patient developed significant anemia, which was resistant to erythropoietin (1,119.0 mUI/mL) and, eventually, required blood transfusion. After transfusion, the patient’s hemoglobin was 6.8 g/dL and her hematocrit was 20.2%.\nIn April 2011, she presented cutaneous mucosa paleness, fatigue after minimal effort, arthropathy and malaise. She presented at the Hospital Felício Rocho, Belo Horizonte, MG, Brazil. Levels of hemoglobin and hematocrit were 3.6 g/dL and 10.3%, respectively. She received a transfusion of 600 mL of erythrocytes. Reticulocyte count was 7,200/mm3, leukocytes 4,100/mm3 and platelet 220,000/mm3. Dosage of serum creatinine was 2.3 mg/dL, iron (152 mcg/dL), transferrin saturation (89.9%), folate level (20.0 ng/mL), ferritin (938.6 ng/mL) and vitamin B12 (238.0 pg/mL), which did not suggest a nutritional or iron deficient anemia. Other laboratory investigations revealed she was seropositive for anti-Epstein-Barr (high IgG levels – 477.0 U/mL) and Cytomegalovirus (IgG positive) and negative for anti-hepatitis B, anti-hepatitis C and anti-HIV antibodies.\nAt this time point, a bone marrow aspirate revealed hypocellular for red and white cells and platelets. Besides, there were dysplasia and megaloblastosis in the erythrocytic series, which were attributed to azathioprine associated with tacrolimus toxicity.\nA bone marrow biopsy was also obtained and showed severe hypoplasia of elements of the erythroid lineage, presence of larger cells with clear nuclei chromatin and eosinophilic nuclear inclusions, suggesting inclusions caused by B19. Nonetheless this evidence has indicated B19 infection, IgM and IgG assays were negative. However, as the symptoms and bone marrow biopsy were suggestive of B19 infection, a qualitative PCR testing for parvovirus B19 was performed, revealing the presence of this virus.\nThe woman received 5 doses of intravenous gammaglobulin, 400 mg/Kg body weight daily, which improved the symptoms. A new evaluation revealed an important increase in hemoglobin, from 3.6 to 12.6 g/dL.", + "fulltext_subclaims": [ + "The patient is a 42-year-old Brazilian woman.", + "She had renal failure and was submitted to haemodialysis for five years.", + "She had a kidney transplant in 2007.", + "After transplantation, the therapeutic regimen of immunosuppression included prednisone (5 mg daily), tacrolimus (5 mg daily), and azathioprine (50 mg daily).", + "Dosage of serum tacrolimus was 5.8 ng/mL.", + "The donor’s B19 status for this recipient was unknown.", + "In December 2010, the patient developed significant anemia.", + "The anemia was resistant to erythropoietin (1,119.0 mUI/mL).", + "The patient eventually required blood transfusion.", + "After transfusion, the patient’s hemoglobin was 6.8 g/dL.", + "After transfusion, the patient’s hematocrit was 20.2%.", + "In April 2011, she presented cutaneous mucosa paleness, fatigue after minimal effort, arthropathy, and malaise.", + "She presented at the Hospital Felício Rocho, Belo Horizonte, MG, Brazil.", + "At presentation, hemoglobin was 3.6 g/dL.", + "At presentation, hematocrit was 10.3%.", + "She received a transfusion of 600 mL of erythrocytes.", + "Reticulocyte count was 7,200/mm3.", + "Leukocytes were 4,100/mm3.", + "Platelet count was 220,000/mm3.", + "Serum creatinine was 2.3 mg/dL.", + "Iron level was 152 mcg/dL.", + "Transferrin saturation was 89.9%.", + "Folate level was 20.0 ng/mL.", + "Ferritin was 938.6 ng/mL.", + "Vitamin B12 was 238.0 pg/mL.", + "The laboratory findings did not suggest a nutritional or iron deficient anemia.", + "She was seropositive for anti-Epstein-Barr (high IgG levels – 477.0 U/mL).", + "She was seropositive for Cytomegalovirus (IgG positive).", + "She was negative for anti-hepatitis B antibodies.", + "She was negative for anti-hepatitis C antibodies.", + "She was negative for anti-HIV antibodies.", + "A bone marrow aspirate revealed hypocellularity for red and white cells and platelets.", + "There were dysplasia and megaloblastosis in the erythrocytic series.", + "The dysplasia and megaloblastosis were attributed to azathioprine associated with tacrolimus toxicity.", + "A bone marrow biopsy showed severe hypoplasia of elements of the erythroid lineage.", + "The bone marrow biopsy showed presence of larger cells with clear nuclei chromatin.", + "The bone marrow biopsy showed eosinophilic nuclear inclusions.", + "The findings suggested inclusions caused by B19.", + "IgM and IgG assays were negative.", + "A qualitative PCR testing for parvovirus B19 was performed.", + "The PCR testing revealed the presence of parvovirus B19.", + "The woman received 5 doses of intravenous gammaglobulin, 400 mg/Kg body weight daily.", + "The symptoms improved after the gammaglobulin treatment.", + "A new evaluation revealed an important increase in hemoglobin, from 3.6 to 12.6 g/dL." + ], + "summary": "Herein we report a kidney transplant recipient, who was unresponsive to treatment of severe anemia, and presented hypocellular hematopoietic marrow, megaloblastosis and hypoplasia of erythroid lineage with larger cells with clear nuclei chromatin and eosinophilic nuclear inclusions. This patient was seropositive for Epstein-Barr and Cytomegalovirus infections and negative for anti-parvovirus B19 IgM and IgG antibodies, although symptoms were suggestive of parvoviruses infection. A qualitative polymerase chain reaction testing for B19 in serum sample revealed positive results for B19 virus DNA.", + "summary_subclaims": [ + "The patient was a kidney transplant recipient.", + "The patient was unresponsive to treatment of severe anemia.", + "The patient presented hypocellular hematopoietic marrow.", + "The patient had megaloblastosis.", + "The patient had hypoplasia of erythroid lineage.", + "The erythroid lineage cells were larger with clear nuclei chromatin.", + "The erythroid lineage cells had eosinophilic nuclear inclusions.", + "The patient was seropositive for Epstein-Barr virus infection.", + "The patient was seropositive for Cytomegalovirus infection.", + "The patient was negative for anti-parvovirus B19 IgM antibodies.", + "The patient was negative for anti-parvovirus B19 IgG antibodies.", + "Symptoms were suggestive of parvovirus infection.", + "A qualitative polymerase chain reaction testing for B19 in serum sample revealed positive results for B19 virus DNA." + ] + }, + { + "id": "multiclinsum_test_564_en.txt", + "fulltext": "A 16-year old male patient consulted the maxillo-facial and oral surgery outpatient clinic of the Chris Hani Baragwanath Academic Hospital (Johannesburg, South Africa) complaining of severe facial deformity and inability to open his mouth. The patient’s history was significant for bilateral post-traumatic TMJ ankylosis sustained at the age of 4 years. He was treated with gap arthroplasty and bilateral costochondral grafts at the age of 8 years. Thereafter, his mouth opening gradually decreased and multiple jaw stretching procedures were performed under general anaesthesia.\nFive years later, chin asymmetry and concomitant malocclusion became apparent and subsequent diagnosis of right CCG overgrowth and reankylosis on the left side was made. A gap arthroplasty was performed on the left side, however the patient returned a year later with bilateral TMJ reankylosis .\nThe clinical examination revealed facial asymmetry with deviation of the mandibular midline to the left. His mouth opening was restricted to approximately 5 mm interdental distance (IDD). He also presented with a cant in the occlusal plane and marked malocclusion. A and B show pre-operative mouth opening at 8 year and 16 years.\nRadiographic investigation included PA mandible (A), orthopantomogram (B) and coronal CT Scans (C). These images confirmed elongation of the vertical ramus on the right side, asymmetry of the chin towards the left side and bilateral ankylosis of the TMJ (yellow arrows) with right mandibular overgrowth (white arrows) respectively.\nIn view of the severity of the deformity, combined orthognathics and TMJ reconstruction with custom joints was planned. The procedure and custom-made prostheses were planned using 3D imaging and stereolithic model generated from his CT scan . Surgical release of bilateral ankylotic masses was carried out using surgical guides via Al-Kayat and Bramley (modified preauricular) and Risdon submandibular approach. Temporomandibular joints were reconstructed with Biomet Microfixation patient-matched alloplastic TMJ prostheses . An IDD of 35 mm was achieved. Facial asymmetry, occlusal plane cant and cross-bite were corrected with Le fort I osteotomy and a genioplasty .\nAt the time of his 12 month postoperative evaluation, he had a maximum mouth opening of 30 mm IDD and his functional and aesthetic evaluation was satisfactory .", + "fulltext_subclaims": [ + "The patient is a 16-year old male.", + "He consulted the maxillo-facial and oral surgery outpatient clinic.", + "He complained of severe facial deformity.", + "He had an inability to open his mouth.", + "The patient had bilateral post-traumatic TMJ ankylosis sustained at the age of 4 years.", + "He was treated with gap arthroplasty and bilateral costochondral grafts at the age of 8 years.", + "His mouth opening gradually decreased after the age of 8 years.", + "Multiple jaw stretching procedures were performed under general anaesthesia.", + "Five years later, chin asymmetry became apparent.", + "Concomitant malocclusion became apparent.", + "The diagnosis was right CCG overgrowth and reankylosis on the left side.", + "A gap arthroplasty was performed on the left side.", + "The patient returned a year later with bilateral TMJ reankylosis.", + "The clinical examination revealed facial asymmetry.", + "The mandibular midline was deviated to the left.", + "His mouth opening was restricted to approximately 5 mm interdental distance.", + "He presented with a cant in the occlusal plane.", + "He had marked malocclusion.", + "Radiographic investigation included PA mandible.", + "Radiographic investigation included orthopantomogram.", + "Radiographic investigation included coronal CT Scans.", + "The images confirmed elongation of the vertical ramus on the right side.", + "The images showed asymmetry of the chin towards the left side.", + "Bilateral ankylosis of the TMJ was confirmed.", + "Right mandibular overgrowth was confirmed.", + "Combined orthognathics and TMJ reconstruction with custom joints was planned.", + "The procedure and custom-made prostheses were planned using 3D imaging.", + "The procedure and custom-made prostheses were planned using stereolithic model generated from his CT scan.", + "Surgical release of bilateral ankylotic masses was carried out using surgical guides.", + "The Al-Kayat and Bramley (modified preauricular) approach was used.", + "The Risdon submandibular approach was used.", + "Temporomandibular joints were reconstructed with Biomet Microfixation patient-matched alloplastic TMJ prostheses.", + "An interdental distance of 35 mm was achieved.", + "Facial asymmetry was corrected with Le fort I osteotomy and a genioplasty.", + "Occlusal plane cant was corrected with Le fort I osteotomy and a genioplasty.", + "Cross-bite was corrected with Le fort I osteotomy and a genioplasty.", + "At the time of his 12 month postoperative evaluation, he had a maximum mouth opening of 30 mm interdental distance.", + "His functional and aesthetic evaluation was satisfactory." + ], + "summary": "We present a case of a 16 year old patient who returned with excessive mandibular growth and TMJ reankylosis following treatment of TMJ ankylosis with CCGs when he was 8 years old.", + "summary_subclaims": [ + "The patient is a 16 year old.", + "The patient returned with excessive mandibular growth.", + "The patient had TMJ reankylosis.", + "The patient had treatment of TMJ ankylosis with CCGs when he was 8 years old." + ] + }, + { + "id": "multiclinsum_test_683_en.txt", + "fulltext": "A 34-year-old female was admitted for traumatic brain injury. She slipped on the bathroom floor and fell, resulting in loss of consciousness. She regained consciousness after a few minutes but did not seek consult. She was initially well but started to complain of intermittent right-sided headache 3 days postinjury, prompting consult at a general clinic. Cranial CT scan showed a large acute epidural hematoma on the right temporal area, measuring 41 cc in volume and resulting in a midline shift of 0.4 cm. The lateral and third ventricles were enlarged but did not exhibit transependymal effusion, and the cerebral sulci were effaced. There was also a linear and nondisplaced right temporal bone fracture [-]. She was advised to seek neurosurgical consult at the emergency room but did not comply until the 5th day postinjury.\nHer medical history was significant for a diagnosis of congenital hydrocephalus from aqueductal stenosis, but she did not undergo surgery. She was also an epileptic maintained on phenobarbital, with the last seizure episode occurring about 15 years ago. She had a recent history of mild COVID-19 infection 5 months prior. Despite having hydrocephalus, she did not exhibit developmental delays as a child and underwent schooling at the proper age. She finished high school at the top of her class, earned a bachelor’s degree at age 20, and is currently pursuing a master’s degree while employed full time.\nOn examination, the patient had a Glasgow Coma Scale (GCS) of 15 with equal and briskly reactive pupils. She was slightly macrocephalic, and her head circumference of 59 cm was in the upper 97th percentile when plotted against her height. Her visual acuity was 20/25 bilaterally, and fundoscopic examination did not show papilledema. She did not have any craniopathies or sensory or motor deficits. A repeat cranial CT scan performed on the 5th day postinjury showed stable size of the hematoma. She still had mild headache, but it was markedly decreased in severity compared to 2 days prior.\nBecause the patient was asymptomatic except for mild headache and was already on the 5th postinjury day, it was decided to treat the patient conservatively with analgesics and close clinical monitoring at the neurosurgical ward. The patient’s headache resolved and she did not develop any deficits; thus, she was sent home on the 8th day postinjury.\nA repeat cranial CT scan was performed 3-week postinjury, which showed a decrease in the size and attenuation of the epidural hematoma. A transcranial Doppler study revealed that the pulsatility indices of all the intracranial arteries were within normal limits and did not show signs of increased intracranial pressure.\nThe patient’s latest follow-up was at 10-month postinjury. She continued to be well and asymptomatic and did not have any new complaints.", + "fulltext_subclaims": [ + "The patient was a 34-year-old female.", + "She was admitted for traumatic brain injury.", + "She slipped on the bathroom floor and fell, resulting in loss of consciousness.", + "She regained consciousness after a few minutes.", + "She did not seek consult.", + "She started to complain of intermittent right-sided headache 3 days postinjury.", + "Cranial CT scan showed a large acute epidural hematoma on the right temporal area.", + "The epidural hematoma measured 41 cc in volume.", + "The midline shift was 0.4 cm.", + "The lateral and third ventricles were enlarged.", + "The cerebral sulci were effaced.", + "There was a linear and nondisplaced right temporal bone fracture.", + "She was advised to seek neurosurgical consult at the emergency room.", + "She did not comply until the 5th day postinjury.", + "Her medical history was significant for congenital hydrocephalus from aqueductal stenosis.", + "She did not undergo surgery for hydrocephalus.", + "She was an epileptic maintained on phenobarbital.", + "Her last seizure episode occurred about 15 years ago.", + "She had a recent history of mild COVID-19 infection 5 months prior.", + "She did not exhibit developmental delays as a child.", + "She finished high school at the top of her class.", + "She earned a bachelor’s degree at age 20.", + "She is currently pursuing a master’s degree.", + "She is employed full time.", + "On examination, the patient had a Glasgow Coma Scale (GCS) of 15.", + "Her pupils were equal and briskly reactive.", + "Her head circumference was 59 cm.", + "Her head circumference was in the upper 97th percentile when plotted against her height.", + "Her visual acuity was 20/25 bilaterally.", + "Fundoscopic examination did not show papilledema.", + "She did not have any craniopathies.", + "She did not have any sensory or motor deficits.", + "A repeat cranial CT scan performed on the 5th day postinjury showed stable size of the hematoma.", + "She still had mild headache.", + "The headache was markedly decreased in severity compared to 2 days prior.", + "It was decided to treat the patient conservatively with analgesics and close clinical monitoring.", + "The patient’s headache resolved.", + "She did not develop any deficits.", + "She was sent home on the 8th day postinjury.", + "A repeat cranial CT scan was performed 3-week postinjury.", + "The repeat CT scan showed a decrease in the size and attenuation of the epidural hematoma.", + "A transcranial Doppler study revealed that the pulsatility indices of all the intracranial arteries were within normal limits.", + "The transcranial Doppler study did not show signs of increased intracranial pressure.", + "The patient’s latest follow-up was at 10-month postinjury.", + "She continued to be well and asymptomatic.", + "She did not have any new complaints." + ], + "summary": "To the best of our knowledge, we present the only reported case of a 34-year-old female with arrested hydrocephalus who sustained an acute epidural hematoma secondary to a fall and underwent a conservative management. She was asymptomatic except for mild headache that started on the 3rd day postinjury and was thus treated conservatively with favorable outcomes. A review of literature showed that adults with arrested hydrocephalus may develop intracranial hematomas after head injuries despite them manifesting with little or no symptoms. The hydrocephalus may have provided them with a form of internal decompression thus delaying symptomatology.", + "summary_subclaims": [ + "We present the only reported case of a 34-year-old female with arrested hydrocephalus who sustained an acute epidural hematoma secondary to a fall and underwent a conservative management.", + "She was asymptomatic except for mild headache that started on the 3rd day postinjury.", + "She was thus treated conservatively with favorable outcomes.", + "A review of literature showed that adults with arrested hydrocephalus may develop intracranial hematomas after head injuries.", + "Adults with arrested hydrocephalus may manifest with little or no symptoms.", + "The hydrocephalus may have provided them with a form of internal decompression.", + "The hydrocephalus may have delayed symptomatology." + ] + }, + { + "id": "multiclinsum_test_1040_en.txt", + "fulltext": "Our patient was a 75-year-old Iranian man, admitted to hospital with recurrent upper abdominal pain for the past 18 months. A common bile duct plastic stent had been inserted based on the results of diagnostic investigations, including an obstructive pattern of liver enzyme elevation, dilatation of extra- and intrahepatic bile ducts revealed through ultrasonography and heterogeneity of the pancreatic head (likely due to cancer) in an abdominal spiral CT scan with oral- and venous-contrast media . No abnormalities were found during a physical examination, with the exception of mild upper abdominal tenderness and vitiligo patches on his neck and hands .\nAn upper gastrointestinal endoscopy, aimed at controlling the presence of occult blood in his stool, iron deficiency anemia and heartburn, showed lower esophageal ulcers associated with diaphragmatic herniation. A pathologic evaluation of the ulcer biopsy specimens confirmed reflux esophagitis. A colonoscopy was normal. Mild dilatation of his extra- and intrahepatic bile ducts was seen in repeated abdominal ultrasonography procedures. However, an endoscopic ultrasound showed a hypoechoic area, 2 cm in size, in the head of his pancreas. The pathological and cytological results of an aspiration biopsy of the lesion revealed fibrosis and inflammatory cell infiltration without evidence of malignancy .\nOnce AIP had been diagnosed, prednisolone was administered. Two months after treatment, a reevaluation of the pancreas head by means of an abdominal spiral CT scan with oral and venous contrast media did not show any abnormality, and the common bile duct stent was removed because of the positive therapeutic response.", + "fulltext_subclaims": [ + "The patient was a 75-year-old Iranian man.", + "He had recurrent upper abdominal pain for the past 18 months.", + "A common bile duct plastic stent had been inserted.", + "Diagnostic investigations included an obstructive pattern of liver enzyme elevation.", + "Ultrasonography showed dilatation of extra- and intrahepatic bile ducts.", + "An abdominal spiral CT scan showed heterogeneity of the pancreatic head.", + "The heterogeneity was likely due to cancer.", + "No abnormalities were found during physical examination.", + "Mild upper abdominal tenderness was noted.", + "Vitiligo patches were present on his neck and hands.", + "An upper gastrointestinal endoscopy was aimed at controlling occult blood in his stool.", + "The endoscopy was aimed at controlling iron deficiency anemia.", + "The endoscopy was aimed at controlling heartburn.", + "Lower esophageal ulcers were found.", + "Diaphragmatic herniation was found.", + "A pathologic evaluation of the ulcer biopsy specimens confirmed reflux esophagitis.", + "A colonoscopy was normal.", + "Mild dilatation of extra- and intrahepatic bile ducts was seen in repeated abdominal ultrasonography.", + "An endoscopic ultrasound showed a hypoechoic area, 2 cm in size, in the head of the pancreas.", + "The pathological and cytological results of the aspiration biopsy revealed fibrosis.", + "The pathological and cytological results showed inflammatory cell infiltration.", + "The pathological and cytological results showed no evidence of malignancy.", + "AIP was diagnosed.", + "Prednisolone was administered.", + "Two months after treatment, a reevaluation of the pancreas head by abdominal spiral CT scan did not show any abnormality.", + "The common bile duct stent was removed because of the positive therapeutic response." + ], + "summary": "A 70-year-old Iranian man presented with recurrent abdominal pain, jaundice and elevated bilirubin and alkaline phosphatase levels. An abdominal computed tomography scan revealed a heterogeneous presence in the pancreatic head as well as dilated intra- and extrahepatic bile ducts. A common bile duct stent had been inserted. Our patient was subsequently diagnosed with pancreatic head cancer.Due to his continued recurrent abdominal pain, our patient returned to the hospital. His levels of bilirubin, alkaline phosphatase and tumor markers were all normal but his immunoglobulin G4 and antinuclear antibodies were extremely high. A biopsy of the pancreatic head heterogeneity by endoscopic ultrasonography was performed.Pathologic samples showed fibrosis associated with lymphoplasmacytic infiltration and no evidence of malignancy. A diagnosis of autoimmune pancreatitis was confirmed, the bile duct stent removed, and an appropriate treatment plan was undertaken.", + "summary_subclaims": [ + "A 70-year-old Iranian man presented with recurrent abdominal pain.", + "The patient had jaundice.", + "The patient had elevated bilirubin levels.", + "The patient had elevated alkaline phosphatase levels.", + "An abdominal computed tomography scan revealed a heterogeneous presence in the pancreatic head.", + "An abdominal computed tomography scan revealed dilated intra- and extrahepatic bile ducts.", + "A common bile duct stent had been inserted.", + "The patient was diagnosed with pancreatic head cancer.", + "The patient returned to the hospital due to continued recurrent abdominal pain.", + "The patient's bilirubin levels were normal.", + "The patient's alkaline phosphatase levels were normal.", + "The patient's tumor markers were normal.", + "The patient's immunoglobulin G4 was extremely high.", + "The patient's antinuclear antibodies were extremely high.", + "A biopsy of the pancreatic head heterogeneity by endoscopic ultrasonography was performed.", + "Pathologic samples showed fibrosis associated with lymphoplasmacytic infiltration.", + "Pathologic samples showed no evidence of malignancy.", + "A diagnosis of autoimmune pancreatitis was confirmed.", + "The bile duct stent was removed.", + "An appropriate treatment plan was undertaken." + ] + }, + { + "id": "multiclinsum_test_3114_en.txt", + "fulltext": "61-year-old man was referred to the cardiologist at a highly specialized Danish university hospital, Rigshospitalet, for an evaluation of severe congestive heart failure (CHF) in 2017. He had a history of CHF, dilated cardiomyopati since many years and left ventricular ejection fraction at 20%. About half a year ago, he had an ablation due to tendency to ventricular tachycardia. He was assessed to NYHA class III and had multiple heart failure-related hospitalizations in the past few years. He presented a clinical challenge, as it was difficult to control his fluid balance. He was deemed a candidate for a CardioMEMS device, which was implanted in the fall 2018 without complications. His pulmonary artery pressure was found too high, and subsequently tried lowered by many different kinds of diuretics. However, trying to drain his fluid overload by diuretics turned out to have severe adverse effects:\n\n○ Kidney parameters increased rapidly\n○ Hypokalemia\n○ Ventricular tachycardia\nIn a little more than 3 months’ time, the patient went from a state of CHF with diuresis to a state with chronic kidney disease and anuria. He started on a hemodialysis regime with in-hospital dialysis three times weekly through a central venous catheter. After 8 dialysis sessions, he was in start 2019 referred to Department of Nephrology at a bigger university hospital outside Copenhagen, North Zealand University Hospital, Hillerød. This rare combination of having an implanted CardioMEMS device and ongoing hemodialysis gave the possibility to invasively monitor pulmonary pressure in course of the dialysis sessions, and compare the results to clinical assessment and bioimpedance analysis. The sessions were conducted. Bioimpedance2. Bioimpedance (BIA) was measured by a multifrequency portable whole-body bioimpedance spectroscopy device (Fresenius Medical care). By intradialytic hypotension is understood a decrease in systemic blood pressure along with clinical symptoms as assessed by the responsible dialysis nurse. Pre-dialytic blood samples was planned once weekly. Endpoint was set to be either 10 dialysis, patient death or withdrawal for other reasons.", + "fulltext_subclaims": [ + "The patient is a 61-year-old man.", + "He was referred to the cardiologist at Rigshospitalet, a highly specialized Danish university hospital.", + "The referral was for an evaluation of severe congestive heart failure in 2017.", + "He had a history of dilated cardiomyopathy.", + "He had a left ventricular ejection fraction of 20%.", + "About half a year before the evaluation, he had an ablation due to tendency to ventricular tachycardia.", + "He was assessed to NYHA class III.", + "He had multiple heart failure-related hospitalizations in the past few years.", + "It was difficult to control his fluid balance.", + "He was deemed a candidate for a CardioMEMS device.", + "The CardioMEMS device was implanted in the fall of 2018 without complications.", + "His pulmonary artery pressure was found too high.", + "He was treated with many different kinds of diuretics.", + "Trying to drain his fluid overload by diuretics turned out to have severe adverse effects.", + "Kidney parameters increased rapidly.", + "He developed hypokalemia.", + "He had ventricular tachycardia.", + "In a little more than 3 months, the patient went from a state of CHF with diuresis to a state with chronic kidney disease and anuria.", + "He started on a hemodialysis regime with in-hospital dialysis three times weekly through a central venous catheter.", + "After 8 dialysis sessions, he was referred to the Department of Nephrology at North Zealand University Hospital, Hillerød.", + "The patient had an implanted CardioMEMS device.", + "The patient was undergoing hemodialysis.", + "The combination of having an implanted CardioMEMS device and ongoing hemodialysis gave the possibility to invasively monitor pulmonary pressure during dialysis sessions.", + "Bioimpedance was measured by a multifrequency portable whole-body bioimpedance spectroscopy device (Fresenius Medical Care).", + "Intradialytic hypotension was defined as a decrease in systemic blood pressure along with clinical symptoms as assessed by the responsible dialysis nurse.", + "Pre-dialytic blood samples were planned once weekly.", + "The endpoint was set to be either 10 dialysis sessions, patient death, or withdrawal for other reasons." + ], + "summary": "61-year old male with known congestive heart failure deteriorated over 3 months’ time from a state with congestive heart failure and diuresis to a state of chronic kidney disease and anuria. He began a thrice/week in-hospital hemodialysis regime. As he already had implanted a CardioMEMS device due to his heart condition, we were able to monitor invasive pulmonary artery pressure during the course of dialysis sessions. To compare, we estimated overhydration by both bioimpedance and clinical assessment. Pulmonary artery pressure correlated closely with fluid drainage during dialysis and inter-dialytic weight gain. The patient reached prescribed dry weight but remained pulmonary hypertensive by definition. During two episodes of intradialytic systemic hypotension, the patient still had pulmonary hypertension by current definition.", + "summary_subclaims": [ + "The patient is a 61-year-old male.", + "The patient has known congestive heart failure.", + "The patient deteriorated over 3 months.", + "The patient transitioned from congestive heart failure and diuresis to chronic kidney disease and anuria.", + "The patient began a thrice/week in-hospital hemodialysis regime.", + "The patient already had an implanted CardioMEMS device.", + "The CardioMEMS device was implanted due to the patient's heart condition.", + "Invasive pulmonary artery pressure was monitored during dialysis sessions.", + "Overhydration was estimated by both bioimpedance and clinical assessment.", + "Pulmonary artery pressure correlated closely with fluid drainage during dialysis.", + "Pulmonary artery pressure correlated closely with inter-dialytic weight gain.", + "The patient reached prescribed dry weight.", + "The patient remained pulmonary hypertensive by definition.", + "During two episodes of intradialytic systemic hypotension, the patient still had pulmonary hypertension by current definition." + ] + }, + { + "id": "multiclinsum_test_2477_en.txt", + "fulltext": "A 57-year-old female patient suffered from irregular vaginal bleeding for 5 mo.\nNo other abnormal clinical signs.\nThe patient underwent cervical conization in 2000 because of atypical epithelial cells in the cervix. Postoperative cervical human papillomavirus (HPV) screening showed no abnormalities. Elevated carbohydrate antigen (CA) 125 and CA199 levels were found 9 years before.\nThe patient denied any family history of malignancies.\nOn physical examination, the patient’s body temperature, pulse, and breathing were normal, and vital signs were stable.\nSerum analysis showed elevated levels of CA125 (114.5 U/mL), CA199 (> 700 U/mL), and human epididymis protein 4 (HE4) (121 mol/L).\nComputed tomography (CT) examination in our hospital showed a solid cystic mass 5.9 cm × 8.3 cm × 6.7 cm in size in the left pelvis and a solid cystic mass 3.6 cm × 3.7 cm × 3.8 cm in the right adnexa .", + "fulltext_subclaims": [ + "The patient is a 57-year-old female.", + "The patient suffered from irregular vaginal bleeding for 5 mo.", + "The patient had no other abnormal clinical signs.", + "The patient underwent cervical conization in 2000.", + "The conization was due to atypical epithelial cells in the cervix.", + "Postoperative cervical HPV screening showed no abnormalities.", + "Elevated CA125 and CA199 levels were found 9 years before.", + "The patient denied any family history of malignancies.", + "The patient’s body temperature, pulse, and breathing were normal.", + "Serum analysis showed elevated levels of CA125 (114.5 U/mL).", + "Serum analysis showed elevated levels of CA199 (> 700 U/mL).", + "Serum analysis showed elevated levels of HE4 (121 mol/L).", + "CT showed a solid cystic mass 5.9 cm × 8.3 cm × 6.7 cm in the left pelvis.", + "CT showed a solid cystic mass 3.6 cm × 3.7 cm × 3.8 cm in the right adnexa." + ], + "summary": "A 57-year-old postmenopausal woman had a 6-month history of irregular uterine bleeding. The uterus and adnexa were examined by computed tomography, and there were two solid cystic masses in the pelvis and right adnexa. Histological findings of surgical specimens showed well-differentiated SCC arising from squamous metaplasia of ectopic endometrial glands in the uterus and ovaries. The patient received chemotherapy after surgery and was followed up for 3 mo without metastasis.", + "summary_subclaims": [ + "The patient is a 57-year-old postmenopausal woman.", + "She had a 6-month history of irregular uterine bleeding.", + "Computed tomography was used to examine the uterus and adnexa.", + "There were two solid cystic masses in the pelvis and right adnexa.", + "Histological findings showed well-differentiated SCC arising from squamous metaplasia of ectopic endometrial glands in the uterus and ovaries.", + "The patient received chemotherapy after surgery.", + "The patient was followed up for 3 mo without metastasis." + ] + }, + { + "id": "multiclinsum_test_2997_en.txt", + "fulltext": "We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarct. She had presented with central chest pain radiating down her left arm with ECG findings of 2 mm ST elevation in V2 and V3. There was no recent history of psychological stress although she had been on antidepressant drugs for two years. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. At this stage it was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.\nShe was transferred on heparin and glyceryl trinitrate infusion, in acute pulmonary oedema (confirmed by chest X-ray), with a systolic blood pressure of 110 mmHg, and heart rate of 130/minute. Urgent echocardiogram showed severe mitral regurgitation (see Figure ). Her mitral valve annulus was slightly widened at 3.2 cm and subvalvular structures were intact. She also had left ventricular apical ballooning (LVAB) and systolic anterior motion (SAM) of the mitral valve leaflet with septal contact – left ventricular outflow tract gradient (LVOT) 60–70 mmHg (see Figures and ). Coronary angiography fourteen hours after her presentation showed no obstructive coronary lesions. Ventriculogram revealed akinesis of the anterolateral wall and apex of her left ventricle, more extensive than any single coronary territory, and grade 4/4 mitral regurgitation (see Figures and ).\nShe had an intra-aortic balloon pump (IABP) inserted and was transferred to theatre shortly thereafter. She was in cardiogenic shock, with severe MR and SAM still prominent, despite the IABP. We elected to replace her mitral valve, and at operation, the mitral valve was mildly myxomatous but there were no structural abnormalities, chordae and papillary muscles being intact. She had a mechanical mitral valve replacement (MVR) with a 29 mm St Jude valve. The anterior leaflet was excised and PTFE (gore-tex CV4) was used to reconstruct the subvalvular apparatus. The posterior leaflet was plicated to the annulus. Post-operatively there was no LV outflow obstruction and ventricular function improved to within normal limits by the 10th post-operative day. She recovered well.", + "fulltext_subclaims": [ + "The patient was a 65 year-old lady.", + "She was treated with thrombolytic therapy for a presumed acute anterior myocardial infarct.", + "She had ECG findings of 2 mm ST elevation in V2 and V3.", + "She had been on antidepressant drugs for two years.", + "Four hours after thrombolysis she developed acute pulmonary oedema.", + "At this stage it was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.", + "She was transferred on heparin and glyceryl trinitrate infusion.", + "Urgent echocardiogram showed severe mitral regurgitation.", + "Her mitral valve annulus was slightly widened at 3.2 cm.", + "Subvalvular structures were intact.", + "She had left ventricular apical ballooning.", + "She had systolic anterior motion of the mitral valve leaflet with septal contact.", + "Coronary angiography showed no obstructive coronary lesions.", + "Ventriculogram revealed akinesis of the anterolateral wall and apex of her left ventricle.", + "The akinesis was more extensive than any single coronary territory.", + "She had grade 4/4 mitral regurgitation.", + "She had an intra-aortic balloon pump inserted.", + "She was in cardiogenic shock.", + "We elected to replace her mitral valve.", + "At operation, the mitral valve was mildly myxomatous.", + "There were no structural abnormalities.", + "Chordae and papillary muscles were intact.", + "She had a mechanical mitral valve replacement with a 29 mm St Jude valve.", + "The anterior leaflet was excised.", + "PTFE was used to reconstruct the subvalvular apparatus.", + "The posterior leaflet was plicated to the annulus.", + "Post-operatively there was no LV outflow obstruction.", + "Ventricular function improved to within normal limits by the 10th post-operative day.", + "She recovered well." + ], + "summary": "We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect. Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60-70 mmHg). Coronary angiography revealed no obstructive coronary lesions.She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well.", + "summary_subclaims": [ + "The patient was a 65 year-old lady.", + "She was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction.", + "Four hours after thrombolysis she developed acute pulmonary oedema.", + "She had a new systolic murmur.", + "It was presumed she had acute mitral regurgitation.", + "Echocardiogram revealed severe mitral regurgitation.", + "Echocardiogram showed left ventricular apical ballooning.", + "Echocardiogram showed systolic anterior motion of the mitral valve.", + "Echocardiogram showed a significant left ventricular outflow tract gradient of 60-70 mmHg.", + "Coronary angiography revealed no obstructive coronary lesions.", + "She had an intra-aortic balloon pump inserted.", + "There was no improvement in her haemodynamic state.", + "We elected to replace her mitral valve.", + "Intra-operatively the mitral valve was mildly myxomatous.", + "There were no structural abnormalities of the mitral valve.", + "She had a mechanical mitral valve replacement with a 29 mm St Jude valve.", + "Post-operatively, her left ventricular outflow obstruction resolved.", + "Ventricular function returned to normal over the subsequent 10 days.", + "She recovered well." + ] + }, + { + "id": "multiclinsum_test_738_en.txt", + "fulltext": "A 71-year-old Japanese man with end-stage renal disease due to diabetic nephropathy was emergently admitted to our hospital because of uremia with fatigue, pulmonary edema, and hyperkalemia. Therefore, hemodialysis was initiated using a temporary blood access catheter on the same day. He gradually recovered his health, and we planned to create an AVF.\nHe was right-handed. Preoperative ultrasonography of the left upper extremity showed good continuity and patency of the cutaneous vein from the wrist to the upper arm. However, the cephalic vein near the wrist was of a poor quality. Moreover, the internal diameter of the radial artery was approximately 2.0 mm in the FIS, and the second dorsal metacarpal vein (SDMV) was approximately 2.3 mm under avascularization. Therefore, we decided to create an RSDAVF in the FIS of the left dorsal hand. Thirteen days after his admission, the operation was successfully performed (A–D).\nThe radial artery, SDMV, tendonof the extensor pollicis longus, and skin incision line were preoperatively indicated using markers (A). The procedure was performed under local anesthesia (1% lidocaine) following a single dose of prophylactic antibiotic (cefazolin 1 g, intravenous), routine disinfection and aseptic shield.\nFirst, a longitudinal 1.5-cm skin incision was made along the slight ulnar side of the artery over the FIS. Next, an approximately 3-cm segment of the vein was dissociated to reach and anastomose with the artery, and an approximately 2-cm segment of the artery was dissociated (B).\nAfter 2000 units of heparin were administered and allowed to circulate for 5 min, the distal part of the vein was ligated and transected proximal to the ligation (C). The vein with visible blood reflux was flushed using a 10-ml syringe connected to a 5-Fr × 45-cm catheter, and by injecting 20–50 ml heparinized saline into the vascular lumen, we confirmed a good thrill. An end-to-side AVF whose anastomotic diameter was approximately 8 mm was then created using continuous 7/0 polypropylene sutures (D), and a good thrill was confirmed.\nFinally, the wound was closed with 4/0 Nylon after we confirmed that no active bleeding was detected in the operative field.\nThe puncture of the RSDAVF was initiated 13 days after the operation. The AVF had developed sufficiently (A), and the blood flow rate during hemodialysis (QB) exceeded 300 mL/min. In addition, not only the superficial veins of the dorsal hand and forearm but also the cephalic and basilic veins in the forearm and upper arm had developed. He was able to receive hemodialysis without problems. The venipuncture sites are shown in B–C, and a schematic illustration of the AVF in the patient’s left hand and forearm is shown in D.\nAbout six months later, he needed percutaneous transluminal angioplasty due to VA stenosis. It was successfully performed, and he has been on hemodialysis for seven months without additional VA interventions.", + "fulltext_subclaims": [ + "The patient was a 71-year-old Japanese man.", + "The patient had end-stage renal disease due to diabetic nephropathy.", + "The patient was emergently admitted to the hospital because of uremia.", + "The patient had fatigue, pulmonary edema, and hyperkalemia.", + "Hemodialysis was initiated using a temporary blood access catheter on the same day.", + "The patient gradually recovered his health.", + "We planned to create an AVF.", + "The patient was right-handed.", + "Preoperative ultrasonography of the left upper extremity showed good continuity and patency of the cutaneous vein from the wrist to the upper arm.", + "The cephalic vein near the wrist was of a poor quality.", + "The internal diameter of the radial artery was approximately 2.0 mm in the FIS.", + "The second dorsal metacarpal vein was approximately 2.3 mm under avascularization.", + "We decided to create an RSDAVF in the FIS of the left dorsal hand.", + "The operation was successfully performed 13 days after his admission.", + "The radial artery, SDMV, tendon of the extensor pollicis longus, and skin incision line were preoperatively indicated using markers.", + "The procedure was performed under local anesthesia (1% lidocaine).", + "A single dose of prophylactic antibiotic (cefazolin 1 g, intravenous) was administered.", + "A longitudinal 1.5-cm skin incision was made along the slight ulnar side of the artery over the FIS.", + "An approximately 3-cm segment of the vein was dissociated to reach and anastomose with the artery.", + "An approximately 2-cm segment of the artery was dissociated.", + "After 2000 units of heparin were administered and allowed to circulate for 5 min, the distal part of the vein was ligated and transected proximal to the ligation.", + "The vein with visible blood reflux was flushed using a 10-ml syringe connected to a 5-Fr × 45-cm catheter.", + "By injecting 20–50 ml heparinized saline into the vascular lumen, we confirmed a good thrill.", + "An end-to-side AVF whose anastomotic diameter was approximately 8 mm was created using continuous 7/0 polypropylene sutures.", + "The wound was closed with 4/0 Nylon after we confirmed that no active bleeding was detected in the operative field.", + "The puncture of the RSDAVF was initiated 13 days after the operation.", + "The AVF had developed sufficiently.", + "The blood flow rate during hemodialysis (QB) exceeded 300 mL/min.", + "The superficial veins of the dorsal hand and forearm had developed.", + "The cephalic and basilic veins in the forearm and upper arm had developed.", + "He was able to receive hemodialysis without problems.", + "About six months later, he needed percutaneous transluminal angioplasty due to VA stenosis.", + "It was successfully performed.", + "He has been on hemodialysis for seven months without additional VA interventions." + ], + "summary": "We herein describe the steps of this technique and its successful performance in a 71-year-old man with end-stage renal disease.", + "summary_subclaims": [ + "We herein describe the steps of this technique.", + "We herein describe its successful performance in a 71-year-old man.", + "The patient had end-stage renal disease." + ] + }, + { + "id": "multiclinsum_test_3131_en.txt", + "fulltext": "A 77-year-old woman visited her local doctor complaining of decreased visual acuity in her left eye for 1 month. She was referred to our Department for further examination and treatment of vitreous opacity in the left eye. She has been on treatment for dermatomyositis, diabetes mellitus, and right parotid tumor with prednisolone (6 mg/day) and tacrolimus hydrate (2 mg/day) for 3 years.\n\nOn the initial visit, the best-corrected visual acuity was 0.04, counting fingers, and the intraocular pressure was 17.0 mmHg and 13.3 mmHg in the right and left eyes, respectively. Slit-lamp microscopy revealed Grade 4 (Emery-Little classification) nuclear cataracts in both eyes, and kerato-precipitates and tan vitreous opacity in the left eye. The left optic nerve head was vaguely observed due to vitreous opacity. B-mode echography of the left eye showed relatively dense vitreous opacity and membranous material on the surface of the retina.\n\nWe considered the tan-like vitreous opacity to be an old vitreous hemorrhage and performed a phacovitrectomy. When the cataract and vitreous opacity were removed, almost total retinal detachment, except for a part of the superior periphery, was observed. Since no retinal break was found and a wide range of thin membrane-like tissue was found on the surface of the retina, the surgeon considered possible PIOL for the first time and performed an unplanned biopsy. The peripheral vitreous was collected as a sample that had already been diluted with irrigating fluid. Therefore, the subretinal fluid was collected through an intentional break to prevent mixing with other fluids. Silicone oil was injected at the end of the surgery. Because the subretinal fluid had slightly increased and involved the macula, re-PPV was performed to further aspirate the subretinal fluid, and the subretinal strand close to the inferior arcade vessel was gently pulled out and collected as a sample. These samples were submitted for cytology, IL-10/IL-6 ratio measurement, and AIGHR. Cytology revealed class II vitreous specimens and class III subretinal fluid (mainly lymphocytes with mild karyotype but no atypia). The pathologist ascertained that the specimen from subretinal fluid was class III, considering the possibility of low-grade MALT lymphoma, which suggests severe dysplasia, carcinoma in situ, or cancer. Cytokine measurements showed that the vitreous fluid was unmeasurable, and the subretinal fluid had a low IL10/IL6 ratio <1.0. The results of AIGHR in the subretinal fluid were positive for monoclonality. The subretinal fluid was gradually reduced, and subtenon injection of triamcinolone acetonide was effective for macular edema. Although the outer retinal layer was atrophic in the macular area, visual acuity in the left eye improved to 0.3. Fundus autofluorescence imaging showed localized hypofluorescent areas corresponding to intentional breaks and surrounding photocoagulated scars. No leakage was observed on fluorescein and indocyanine green fluorescence angiography, and the location of typical subretinal infiltration was unclear. The right eye underwent cataract surgery and visual acuity improved to 0.9. Fundus examination revealed no abnormal findings including IOL-related changes. There were no positive findings on head-enhanced magnetic resonance imaging or whole-body fluorodeoxyglucose positron emission tomography-computed tomography, and a diagnosis of PIOL was made. No relapse of intraocular inflammation was observed, and the patient was carefully monitored.", + "fulltext_subclaims": [ + "The patient is a 77-year-old woman.", + "She complained of decreased visual acuity in her left eye for 1 month.", + "She was referred to the Department for further examination and treatment of vitreous opacity in the left eye.", + "She has been on treatment for dermatomyositis, diabetes mellitus, and right parotid tumor with prednisolone (6 mg/day) and tacrolimus hydrate (2 mg/day) for 3 years.", + "On the initial visit, the best-corrected visual acuity was 0.04, counting fingers, in the left eye.", + "The intraocular pressure was 17.0 mmHg in the right eye.", + "The intraocular pressure was 13.3 mmHg in the left eye.", + "Slit-lamp microscopy revealed Grade 4 (Emery-Little classification) nuclear cataracts in both eyes.", + "Kerato-precipitates and tan vitreous opacity were observed in the left eye.", + "The left optic nerve head was vaguely observed due to vitreous opacity.", + "B-mode echography of the left eye showed relatively dense vitreous opacity.", + "B-mode echography showed membranous material on the surface of the retina.", + "The tan-like vitreous opacity was considered to be an old vitreous hemorrhage.", + "A phacovitrectomy was performed.", + "When the cataract and vitreous opacity were removed, almost total retinal detachment, except for a part of the superior periphery, was observed.", + "No retinal break was found.", + "A wide range of thin membrane-like tissue was found on the surface of the retina.", + "The surgeon considered possible PIOL for the first time.", + "An unplanned biopsy was performed.", + "The peripheral vitreous was collected as a sample that had already been diluted with irrigating fluid.", + "Subretinal fluid was collected through an intentional break to prevent mixing with other fluids.", + "Silicone oil was injected at the end of the surgery.", + "Re-PPV was performed to further aspirate the subretinal fluid.", + "The subretinal strand close to the inferior arcade vessel was gently pulled out and collected as a sample.", + "The samples were submitted for cytology, IL-10/IL-6 ratio measurement, and AIGHR.", + "Cytology revealed class II vitreous specimens.", + "Cytology revealed class III subretinal fluid (mainly lymphocytes with mild karyotype but no atypia).", + "The pathologist ascertained that the specimen from subretinal fluid was class III.", + "The pathologist considered the possibility of low-grade MALT lymphoma.", + "The subretinal fluid had a low IL10/IL6 ratio <1.0.", + "The results of AIGHR in the subretinal fluid were positive for monoclonality.", + "The subretinal fluid was gradually reduced.", + "Subtenon injection of triamcinolone acetonide was effective for macular edema.", + "Visual acuity in the left eye improved to 0.3.", + "Fundus autofluorescence imaging showed localized hypofluorescent areas corresponding to intentional breaks and surrounding photocoagulated scars.", + "No leakage was observed on fluorescein and indocyanine green fluorescence angiography.", + "The location of typical subretinal infiltration was unclear.", + "The right eye underwent cataract surgery.", + "Visual acuity in the right eye improved to 0.9.", + "Fundus examination revealed no abnormal findings including IOL-related changes.", + "There were no positive findings on head-enhanced magnetic resonance imaging.", + "There were no positive findings on whole-body fluorodeoxyglucose positron emission tomography-computed tomography.", + "A diagnosis of PIOL was made.", + "No relapse of intraocular inflammation was observed.", + "The patient was carefully monitored." + ], + "summary": "A 77-year-old woman developed decreased left visual acuity for 1 month. She had been treated for dermatomyositis, diabetes mellitus, and right parotid tumor for 3 years. Visual acuity was 0.1 OD and counting fingers OS. Slit-lamp examination showed grade 4 (Emery-Little classification) nuclear cataract in both eyes and keratoprecipitates and tan vitreous opacity in the left eye. Fundoscopy details were unclear except for a vaguely observable optic nerve head due to yellow-brown vitreous opacity, which we judged as an old vitreous hemorrhage. Phacovitrectomy was performed and almost total retinal detachment was found, except for a part of the superior periphery. Since no retinal break was found and a wide range of thin membrane-like tissue was found on the surface of the retina, the surgeon suspected primary IOL and performed unplanned biopsy. The peripheral vitreous was collected as a sample, and then the subretinal fluid was collected through an intentional break to prevent mixing with other fluids. The subretinal strand was gently removed and collected. Cytology showed class III, the IL10/IL6 ratio was low, and AIGHR was positive. Postoperatively, fundus autofluorescence showed no abnormality, no leakage was observed on fluorescein and indocyanine green angiography, and the location of typical infiltration lesions under the retina was unclear. There were no positive findings on systemic examinations and a diagnosis of primary IOL was made. The main symptoms of this case were vitreous opacity and exudative retinal detachment, and AIGHR using subretinal fluid was useful for diagnosis.", + "summary_subclaims": [ + "The patient was a 77-year-old woman.", + "She developed decreased left visual acuity for 1 month.", + "She had been treated for dermatomyositis, diabetes mellitus, and right parotid tumor for 3 years.", + "Visual acuity was 0.1 OD and counting fingers OS.", + "Slit-lamp examination showed grade 4 (Emery-Little classification) nuclear cataract in both eyes.", + "Keratoprecipitates were observed in the left eye.", + "Tan vitreous opacity was observed in the left eye.", + "Fundoscopy details were unclear except for a vaguely observable optic nerve head due to yellow-brown vitreous opacity.", + "Phacovitrectomy was performed.", + "Almost total retinal detachment was found, except for a part of the superior periphery.", + "No retinal break was found.", + "A wide range of thin membrane-like tissue was found on the surface of the retina.", + "The surgeon suspected primary IOL.", + "An unplanned biopsy was performed.", + "The peripheral vitreous was collected as a sample.", + "Subretinal fluid was collected through an intentional break to prevent mixing with other fluids.", + "The subretinal strand was gently removed and collected.", + "Cytology showed class III.", + "The IL10/IL6 ratio was low.", + "AIGHR was positive.", + "Postoperatively, fundus autofluorescence showed no abnormality.", + "No leakage was observed on fluorescein and indocyanine green angiography.", + "The location of typical infiltration lesions under the retina was unclear.", + "There were no positive findings on systemic examinations.", + "A diagnosis of primary IOL was made.", + "The main symptoms of this case were vitreous opacity and exudative retinal detachment.", + "AIGHR using subretinal fluid was useful for diagnosis." + ] + }, + { + "id": "multiclinsum_test_407_en.txt", + "fulltext": "We report on a fifty-year-old man who had been suffering from increasing neck pain, burning, and stinging since he was 18 years old. Rotation of the cervical spine to the left or right increased the pain up to a peak level of 6 on the Visual Analog Scale (VAS). Sitting (at the computer) was worst.\nThe patient had been given chiropractic therapy, physiotherapy, and non-steroidal antirheumatics (diclofenac) without success. There was no other illness known, and he did not take any other medication. In this situation, the patient was referred to our pain center by his family doctor.\nAll movements of the cervical spine were limited between 10 and 30°, and at the maximum of the movements, the pain increased. The muscles were in higher tension (especially the levator scapulae and the splenius capitis muscle on both sides). We also found myofascial trigger points in these muscles on both sides. Clinical neurological findings were symmetrical and in order.\nThe X-ray showed a light generalized spondylosis and spondylarthrosis as well as a light chondrosis C5/C6 (that could not explain his pain). Laboratory findings showed no signs of a general inflammation or of any disease.\nIn the first session, we treated the myofascial trigger points and the increased tonus of the muscles mentioned with a well-directed injection of LA procaine 1% (according to neural therapy). These local interventions were not successful. As a routine in such cases, we ordered an orthopantomogram of the teeth, although the patient had no tooth pain. We found 3 M with a space problem at positions 2.8 and 3.8 (ascending mandibular ramus), and an impacted tooth with perifocal inflammation at 4.8 . As a diagnostic test (with the question of an influence on the neck pain, see Discussion), we infiltrated the periodontal tissue of these three teeth with LA procaine 1%. Minutes after these interventions, the patient was nearly free of pain in the neck for the first time since many years. After 1 week, the pain in the neck appeared again, reaching the same level.\nWith this “positive” test, we made the indication for extraction of the teeth 2.8, 3.8, and 4.8. Afterward, the patient was nearly pain free in the neck. Half a year later, his neck pain appeared again to a slight degree (VAS 2–3). Subsequently, we infiltrated the scars of the teeth extractions with procaine 1% in the regions 2.8, 3.8, and 4.8. After this last intervention, the patient was pain free, and he showed almost normal mobility of the cervical spine without increased muscle tone. The freedom from neck pain has lasted for over 3 years.", + "fulltext_subclaims": [ + "The patient was a fifty-year-old man.", + "He had been suffering from increasing neck pain, burning, and stinging since he was 18 years old.", + "Rotation of the cervical spine to the left or right increased the pain up to a peak level of 6 on the Visual Analog Scale.", + "Sitting at the computer was worst.", + "The patient had been given chiropractic therapy without success.", + "The patient had been given physiotherapy without success.", + "The patient had been given non-steroidal antirheumatics (diclofenac) without success.", + "There was no other illness known.", + "The patient did not take any other medication.", + "The patient was referred to the pain center by his family doctor.", + "All movements of the cervical spine were limited between 10 and 30°.", + "At the maximum of the movements, the pain increased.", + "The muscles were in higher tension, especially the levator scapulae and the splenius capitis muscle on both sides.", + "Myofascial trigger points were found in these muscles on both sides.", + "Clinical neurological findings were symmetrical and in order.", + "The X-ray showed a light generalized spondylosis and spondylarthrosis.", + "The X-ray showed a light chondrosis C5/C6.", + "The chondrosis C5/C6 could not explain his pain.", + "Laboratory findings showed no signs of a general inflammation.", + "Laboratory findings showed no signs of any disease.", + "In the first session, the myofascial trigger points and the increased tonus of the muscles were treated with a well-directed injection of LA procaine 1%.", + "These local interventions were not successful.", + "An orthopantomogram of the teeth was ordered.", + "The patient had no tooth pain.", + "Three M with a space problem were found at positions 2.8 and 3.8.", + "An impacted tooth with perifocal inflammation was found at 4.8.", + "The periodontal tissue of these three teeth was infiltrated with LA procaine 1%.", + "Minutes after these interventions, the patient was nearly free of pain in the neck for the first time since many years.", + "After 1 week, the pain in the neck appeared again, reaching the same level.", + "The indication for extraction of the teeth 2.8, 3.8, and 4.8 was made.", + "Afterward, the patient was nearly pain free in the neck.", + "Half a year later, his neck pain appeared again to a slight degree (VAS 2–3).", + "The scars of the teeth extractions were infiltrated with procaine 1% in the regions 2.8, 3.8, and 4.8.", + "After this last intervention, the patient was pain free.", + "The patient showed almost normal mobility of the cervical spine without increased muscle tone.", + "The freedom from neck pain has lasted for over 3 years." + ], + "summary": "We report on a patient with chronic, therapy-resistant neck pain whose cause lied in the tooth/jaw region, specifically, in wisdom teeth with space problems, and partially impacted. The tooth/jaw area itself was not painful; however, neck pain developed via the nucleus spinalis n. trigemini which extends into the cervical medulla. Surgical restoration of the wisdom teeth and subsequent neural therapy treatment of the extraction scars provided permanent pain relief.", + "summary_subclaims": [ + "The patient had chronic, therapy-resistant neck pain.", + "The cause of the neck pain was in the tooth/jaw region.", + "The cause was specifically wisdom teeth with space problems.", + "The wisdom teeth were partially impacted.", + "The tooth/jaw area itself was not painful.", + "Neck pain developed via the nucleus spinalis n. trigemini.", + "The nucleus spinalis n. trigemini extends into the cervical medulla.", + "Surgical restoration of the wisdom teeth was performed.", + "Subsequent neural therapy treatment of the extraction scars was provided.", + "The treatment provided permanent pain relief." + ] + }, + { + "id": "multiclinsum_test_1497_en.txt", + "fulltext": "A 49-year-old man was hospitalized due to pleuropneumonia. Transthoracic echocardiography in parasternal and modified apical view showed a markedly dilated coronary sinus . There was no evidence of valvular heart disease and diameters of cardiac chambers were within normal limits. Systolic and diastolic function of the left ventricle and estimated pulmonary systolic pressure were in normal range. All pulmonary veins drained into the left atrium. In order to reveal the cause of coronary sinus dilation an agitated saline injection was given into the left antecubital vein. The contrast entered first into the coronary sinus and subsequently appeared in the right atrium. Similarly, when the saline injection was given into the right antecubital vein, the contrast agent appeared first in the dilated coronary sinus and thereafter entered into the right atrium . Transesophageal echocardiography showed absence of right SVC, presence of left SVC at lateral border of left atrium and no evidence of any other structural abnormalities of the heart and great thoracic vessels . An upper venous digital subtraction cavography confirmed the absence of the right SVC and the presence of persistent left SVC . Surface electrocardiogram and laboratory exams were within normal limits. Abdominal sonography verified normal position and structure of visceral organs.", + "fulltext_subclaims": [ + "A 49-year-old man was hospitalized due to pleuropneumonia.", + "Transthoracic echocardiography in parasternal and modified apical view showed a markedly dilated coronary sinus.", + "There was no evidence of valvular heart disease.", + "Diameters of cardiac chambers were within normal limits.", + "Systolic and diastolic function of the left ventricle were in normal range.", + "Estimated pulmonary systolic pressure was in normal range.", + "All pulmonary veins drained into the left atrium.", + "An agitated saline injection was given into the left antecubital vein.", + "The contrast entered first into the coronary sinus and subsequently appeared in the right atrium.", + "When the saline injection was given into the right antecubital vein, the contrast agent appeared first in the dilated coronary sinus and thereafter entered into the right atrium.", + "Transesophageal echocardiography showed absence of right SVC.", + "Transesophageal echocardiography showed presence of left SVC at lateral border of left atrium.", + "Transesophageal echocardiography showed no evidence of any other structural abnormalities of the heart and great thoracic vessels.", + "Upper venous digital subtraction cavography confirmed the absence of the right SVC.", + "Upper venous digital subtraction cavography confirmed the presence of persistent left SVC.", + "Surface electrocardiogram was within normal limits.", + "Laboratory exams were within normal limits.", + "Abdominal sonography verified normal position and structure of visceral organs." + ], + "summary": "A 49-year-old man underwent transthoracic echocardiography for atypical chest pain. A dilated coronary sinus was found and venous contrast echocardiography raised the suspicion of absent right and persistent left superior vena cava. Transesophageal echocardiography showed absence of right superior vena cava. The echocardiographic findings were confirmed by upper venous digital subtraction cavography.", + "summary_subclaims": [ + "The patient is a 49-year-old man.", + "The patient underwent transthoracic echocardiography for atypical chest pain.", + "A dilated coronary sinus was found.", + "Venous contrast echocardiography raised the suspicion of absent right and persistent left superior vena cava.", + "Transesophageal echocardiography showed absence of right superior vena cava.", + "The echocardiographic findings were confirmed by upper venous digital subtraction cavography." + ] + }, + { + "id": "multiclinsum_test_2072_en.txt", + "fulltext": "A 63-year-old female (149 cm, 57 kg) was scheduled for elective laparoscopic distal gastrectomy under general anesthesia for gastric cancer. Her prior medical history included cerebral infarction and cervical spondylosis, controlled with medication. When she was 37 years old, she was diagnosed with Isaacs’ syndrome. Whole-body stiffness worsened, and double filtration plasmapheresis (DFPP) was performed four times per year to treat the symptoms.\nThe patient had previously received a surgical arteriovenous shunt in the left forearm, a subcutaneously fixed superficial artery, and an arteriovenous graft in the upper left arm; however, all had occluded within 1 year. Additionally, she had received a thrombectomy of the right femoral vein. As her blood vessels were easily occluded due to frequent vasospasms, a temporary cervical catheter had been used when providing DFPP treatment. The patient orally received tacrolimus (3 mg/day) to suppress the symptoms of Isaacs’ syndrome; dantrolene (150 mg/day), carbamazepine (600 mg/day), and gabapentin (900 mg/day) to relieve the muscle symptoms; dabigatran etexilate methanesulfonate (320 mg/day) as an anticoagulant; cilostazol (150 mg/day) to prevent cerebral infarction; and nicorandil (10 mg/day) as a vasodilator to suppress vasospasms.\nThe results of preoperative examinations were not remarkable except hemoglobin of 10.8 g/dL. The patient had myokymia of the bilateral upper extremities, neuromyotonia of the bilateral thumb, and left ptosis. We classified her physical status as American Society of Anesthesiologists physical status III. She was admitted to the hospital a month prior to the operation to receive DFPP four times.\nWhen she arrived at the operating room, she was hemodynamically stable and treated with dantrolene (50 mg), carbamazepine (200 mg), gabapentin (300 mg), and nicorandil (5 mg) as premedications. We performed preoperative monitoring, including standard monitoring, neuromuscular monitor (TOF-Watch®), and electroencephalogram using the Bispectral Index monitor.\nGeneral anesthesia was induced with 100 μg fentanyl, target-controlled infusion of 2.5 μg/mL propofol, and 50 mg lidocaine after pre-oxygenation with 100% oxygen. After induction, we confirmed that T4/T1 was 100% using the TOF; we then administered 20 mg rocuronium. The time to get a TOF ratio of 0% was 4 min, and endotracheal intubation was carefully performed without complications. Anesthesia was maintained with oxygen, air, propofol (TCI concentration, 2.3 μg/mL), remifentanil (0.15–0.3 μg/kg/min), and intermittent intravenous administration of fentanyl. We also used the minimum amount of muscle relaxant. Rocuronium (10 mg) was administered when the TOF ratio increased to 50%. The total dose of rocuronium was 90 mg. Surgery proceeded uneventfully. For postoperative analgesia, infiltration anesthesia was performed at the rectus sheath with levobupivacaine (0.25%, 20 mL) and an intravenous fentanyl pump (0.5 μg/kg/h) started 1 h before the end of surgery. At the end of the procedure, we confirmed that the TOF ratio had recovered to > 90%. The residual neuromuscular block was antagonized using sugammadex (2 mg/kg), and propofol and remifentanil were discontinued. Shortly afterward, the TOF ratio recovered completely and spontaneous respiration resumed. The patient followed our commands and showed spontaneous breathing, and tracheal extubation was performed. The total operative time was 225 min and the anesthetic duration was 355 min. Subsequent to confirming stable vital signs and neuromuscular symptoms after extubation, the patient was moved to an intensive care unit.\nAfter transfer, she complained about abdominal pain, so the infusion rate of fentanyl was increased to 1.0 μg/kg/h, and dexmedetomidine (0.4 μg/kg/h) was added to control pain. She was discharged to the general ward the day after surgery; however, the abdominal pain worsened because myokymia frequently occurs in the rectus abdominis muscle. The patient complained about severe pain (numerical rating scale, 8/10), so the infusion rate of fentanyl was increased to 2.0 μg/kg/h, which was effective for controlling pain. Afterward, she often experienced vomiting 8 days after surgery. The clinical course seemed to originate from postoperative pyloric stenosis. She received gastric bougie procedures two times after the surgery. The symptoms of Isaacs’ syndrome were stable after the postoperative pain was relieved, and she was discharged on postoperative day 66.", + "fulltext_subclaims": [ + "The patient was a 63-year-old female.", + "She was scheduled for elective laparoscopic distal gastrectomy.", + "The surgery was under general anesthesia.", + "The indication for the surgery was gastric cancer.", + "She had a prior medical history of cerebral infarction.", + "She had a prior medical history of cervical spondylosis.", + "She was diagnosed with Isaacs’ syndrome when she was 37 years old.", + "She had whole-body stiffness.", + "She received double filtration plasmapheresis four times per year.", + "She had a surgical arteriovenous shunt in the left forearm.", + "She had a subcutaneously fixed superficial artery.", + "She had an arteriovenous graft in the upper left arm.", + "All of these vascular access sites had occluded within 1 year.", + "She had received a thrombectomy of the right femoral vein.", + "She orally received tacrolimus (3 mg/day).", + "She orally received dantrolene (150 mg/day).", + "She orally received carbamazepine (600 mg/day).", + "She orally received gabapentin (900 mg/day).", + "She orally received dabigatran etexilate methanesulfonate (320 mg/day).", + "She orally received cilostazol (150 mg/day).", + "She orally received nicorandil (10 mg/day).", + "The preoperative hemoglobin was 10.8 g/dL.", + "She had myokymia of the bilateral upper extremities.", + "She had neuromyotonia of the bilateral thumb.", + "She had left ptosis.", + "She was classified as American Society of Anesthesiologists physical status III.", + "She was admitted to the hospital a month prior to the operation.", + "She received DFPP four times before the operation.", + "She was hemodynamically stable when she arrived at the operating room.", + "She received dantrolene (50 mg) as premedication.", + "She received carbamazepine (200 mg) as premedication.", + "She received gabapentin (300 mg) as premedication.", + "She received nicorandil (5 mg) as premedication.", + "Preoperative monitoring included standard monitoring.", + "Preoperative monitoring included a neuromuscular monitor (TOF-Watch®).", + "Preoperative monitoring included an electroencephalogram using the Bispectral Index monitor.", + "General anesthesia was induced with 100 μg fentanyl.", + "General anesthesia was induced with target-controlled infusion of 2.5 μg/mL propofol.", + "General anesthesia was induced with 50 mg lidocaine.", + "After induction, T4/T1 was 100% using the TOF.", + "She received 20 mg rocuronium.", + "The time to get a TOF ratio of 0% was 4 min.", + "Endotracheal intubation was performed without complications.", + "Anesthesia was maintained with oxygen, air, propofol (TCI concentration, 2.3 μg/mL).", + "Anesthesia was maintained with remifentanil (0.15–0.3 μg/kg/min).", + "Anesthesia was maintained with intermittent intravenous administration of fentanyl.", + "The minimum amount of muscle relaxant was used.", + "Rocuronium (10 mg) was administered when the TOF ratio increased to 50%.", + "The total dose of rocuronium was 90 mg.", + "Surgery proceeded uneventfully.", + "Postoperative analgesia included infiltration anesthesia at the rectus sheath with levobupivacaine (0.25%, 20 mL).", + "An intravenous fentanyl pump (0.5 μg/kg/h) was started 1 h before the end of surgery.", + "At the end of the procedure, the TOF ratio had recovered to > 90%.", + "Residual neuromuscular block was antagonized using sugammadex (2 mg/kg).", + "Propofol and remifentanil were discontinued.", + "The TOF ratio recovered completely shortly afterward.", + "Spontaneous respiration resumed.", + "The patient followed commands and showed spontaneous breathing.", + "Tracheal extubation was performed.", + "The total operative time was 225 min.", + "The anesthetic duration was 355 min.", + "After transfer, she complained about abdominal pain.", + "The infusion rate of fentanyl was increased to 1.0 μg/kg/h.", + "Dexmedetomidine (0.4 μg/kg/h) was added to control pain.", + "She was discharged to the general ward the day after surgery.", + "The abdominal pain worsened because myokymia frequently occurs in the rectus abdominis muscle.", + "She complained about severe pain (numerical rating scale, 8/10).", + "The infusion rate of fentanyl was increased to 2.0 μg/kg/h.", + "The increased fentanyl rate was effective for controlling pain.", + "She often experienced vomiting 8 days after surgery.", + "The clinical course seemed to originate from postoperative pyloric stenosis.", + "She received gastric bougie procedures two times after the surgery.", + "The symptoms of Isaacs’ syndrome were stable after the postoperative pain was relieved.", + "She was discharged on postoperative day 66." + ], + "summary": "A 63-year-old woman with Isaacs' syndrome underwent elective laparoscopic distal gastrectomy under general anesthesia without epidural anesthesia. She received double filtration plasmapheresis four times to alleviate symptoms before surgery. To avoid a prolonged neuromuscular blockade, we performed total intravenous anesthesia and titrated muscle relaxant with neuromuscular monitoring. Anesthetic management was performed without any problems. However, pain management after surgery proved difficult as she experienced severe pain due to myokymia.", + "summary_subclaims": [ + "The patient is a 63-year-old woman with Isaacs' syndrome.", + "She underwent elective laparoscopic distal gastrectomy.", + "The surgery was performed under general anesthesia.", + "Epidural anesthesia was not used.", + "She received double filtration plasmapheresis four times before surgery.", + "The plasmapheresis was intended to alleviate symptoms.", + "Total intravenous anesthesia was performed.", + "Muscle relaxant was titrated with neuromuscular monitoring.", + "Anesthetic management was performed without any problems.", + "Pain management after surgery proved difficult.", + "She experienced severe pain due to myokymia." + ] + }, + { + "id": "multiclinsum_test_3308_en.txt", + "fulltext": "The case of a 79-year-old man with a diagnosis of obesity with no history of asthma, smoking or illicit drug use, who consulted for sudden dyspnoea at rest, was described. On admission to hospital, tachypnoea, generalised hypoventilation and bilateral diffuse wheezing were noted on pulmonary auscultation, sinus tachycardia and pulse oximetry oxygen desaturation of 70% at room air was observed. In the admission laboratory, he presented respiratory failure type 1 (pO2 39 mm Hg), leukocytosis (11 300/mm3), elevated C reactive protein and LDH (17.7 mg/d and 659 U/L respectively) and hyperlactatemia (10 mmol/L). Nasopharyngeal swab with polymerase chain reaction technique for SARS-CoV-2 positive. A thoracic angiotomography was performed that evidenced bilateral areas of ground glass opacities, without evidence of pulmonary thromboembolism. Lower limb venous Doppler without deep vein thrombosis. He underwent an intensive care admission with a diagnosis of bilateral pneumonia by SARS-CoV-2 (CURB-65 of 3 points) with oxygen supply through a mask with reservoir (15 l/min), treatment with dexamethasone and ampicillin-sulbactam. He did not require central venous access or use of positive pressure devices (VNI or high flow nasal cannula). After 72 hours, due to clinical improvement and decrease of oxygen requirements to nasal cannula, he was transferred to the general ward. He improved four days later with access of cough, progression of dyspnoea, tachypnoea (30 rpm), generalised wheezing and increased oxygen requirements. He did not present thoracic pain, palpitations, odynophagia, dysphagia or neck pain. A thoracic tomography was performed where ground glass opacities and cervical subcutaneous emphysema were evidenced. Hamman syndrome was interpreted as secondary to increased intrathoracic pressure due to access of cough and bronchial obstruction. He was treated with inhaled bronchodilators and improved with symptomatic improvement, without oxygen therapy requirements.\n", + "fulltext_subclaims": [ + "The patient is a 79-year-old man.", + "The patient has a diagnosis of obesity.", + "The patient has no history of asthma.", + "The patient has no history of smoking.", + "The patient has no history of illicit drug use.", + "The patient consulted for sudden dyspnoea at rest.", + "On admission, tachypnoea was noted.", + "On admission, generalised hypoventilation was noted.", + "On admission, bilateral diffuse wheezing was noted.", + "On admission, sinus tachycardia was observed.", + "On admission, pulse oximetry oxygen desaturation of 70% at room air was observed.", + "The patient presented respiratory failure type 1 (pO2 39 mm Hg).", + "The patient had leukocytosis (11 300/mm3).", + "The patient had elevated C reactive protein.", + "The patient had elevated LDH (17.7 mg/d and 659 U/L respectively).", + "The patient had hyperlactatemia (10 mmol/L).", + "Nasopharyngeal swab with polymerase chain reaction technique for SARS-CoV-2 was positive.", + "Thoracic angiotomography evidenced bilateral areas of ground glass opacities.", + "Thoracic angiotomography showed no evidence of pulmonary thromboembolism.", + "Lower limb venous Doppler showed no deep vein thrombosis.", + "The patient was admitted to intensive care with a diagnosis of bilateral pneumonia by SARS-CoV-2.", + "The patient received oxygen supply through a mask with reservoir (15 l/min).", + "The patient received treatment with dexamethasone.", + "The patient received treatment with ampicillin-sulbactam.", + "The patient did not require central venous access.", + "The patient did not use positive pressure devices.", + "After 72 hours, the patient was transferred to the general ward.", + "After 72 hours, the patient had clinical improvement.", + "After 72 hours, the patient's oxygen requirements decreased to nasal cannula.", + "Four days later, the patient had access of cough.", + "Four days later, the patient had progression of dyspnoea.", + "Four days later, the patient had tachypnoea (30 rpm).", + "Four days later, the patient had generalised wheezing.", + "Four days later, the patient had increased oxygen requirements.", + "A thoracic tomography was performed.", + "Thoracic tomography showed ground glass opacities.", + "Thoracic tomography showed cervical subcutaneous emphysema.", + "Hamman syndrome was interpreted as secondary to increased intrathoracic pressure due to access of cough and bronchial obstruction.", + "The patient was treated with inhaled bronchodilators.", + "The patient improved with symptomatic improvement.", + "The patient did not require oxygen therapy." + ], + "summary": "We present a 79-year-old patient who, during his admission for pneumonia secondary to the SARS-CoV-2 virus, suddenly developed dyspnoea, chest pain, coughing fits and bronchospasm with a finding of spontaneous pneumomediastinum in the chest tomography. He evolved favorably with bronchodilator treatment and oxygen therapy.\n", + "summary_subclaims": [ + "The patient is a 79-year-old.", + "The patient was admitted for pneumonia.", + "The pneumonia was secondary to the SARS-CoV-2 virus.", + "The patient suddenly developed dyspnoea.", + "The patient had chest pain.", + "The patient had coughing fits.", + "The patient had bronchospasm.", + "Chest tomography showed spontaneous pneumomediastinum.", + "The patient evolved favorably with bronchodilator treatment.", + "The patient received oxygen therapy." + ] + }, + { + "id": "multiclinsum_test_91_en.txt", + "fulltext": "We report here the case of an 82-year-old Japanese woman who had received yearly intravenous denosumab for 4 years and presented with a fracture fulfilling the criteria for an atypical fracture, except for being located at the tibial diaphysis. There was no history of bisphosphonate or oral glucocorticoid use. She was found to have stage 4 breast cancer with multiple bone metastases 4 years prior. Since then, she has been treated with an aromatase inhibitor and denosumab.\nThe patient had no obvious history of trauma. One day, while walking, pain appeared in her left shin. A few days after the pain occurred, she visited an outpatient orthopedic clinic. X-ray images from the initial visit are shown below .\nBecause her fracture was without any accompanying dislocation, she was followed up at home with full weight bearing on her left leg. Her pain persisted for a month after the initial visit, and she had difficulty walking because of the shin pain. She returned to the orthopedic outpatient clinic, and X-ray images demonstrated a non-displaced transverse fracture of the proximal third of the left tibial diaphysis .\nShe had multiple bone metastases to several spinal and pelvic bones 4 years prior, due to breast cancer. .\nThe tibial fracture was also considered a differential for a pathological fracture due to a metastatic bone tumor. Therefore, the patient underwent additional imaging examination, including CT and MRI scans. The CT and MRI images did not show any positive findings to suggest a metastatic bone tumor, but they could not rule out the possibility either. At the time of the fracture, the serum biochemical parameters of bone metabolism and cancer markers were 25-hydroxyvitamin D 32 ng/mL, total calcium 10.3 mg/dL, tartrate-resistant acid phosphatase 5b (TRACP-5b) 192 mU/dL, carcinoembryonic antigen (CEA) 66.3 ng/mL, and cancer antigen 15-3 (CA15-3) 109.7 U/mL.\nHer tibial fracture pattern fulfilled all the major criteria (except for the location) and several minor criteria of an atypical fracture. We suspected from these findings that her tibial fracture was atypical.\nShe had difficulty walking due to pain and underwent surgical treatment. Treatment consisted of an intramedullary nail that immediately resolved the pain . The cancellous bone within the medullary cavity of the fracture was harvested during intramedullary reaming. The skin near the medial fracture site was also incised, and external periosteum and bone tissue around the fracture site were collected. Pathological examinations were performed on both bone tissue samples. Both samples had no neoplastic changes that could be considered breast cancer-associated bone metastases. Therefore, a pathological fracture due to bone metastases from breast cancer was ruled out, and we diagnosed her tibial fracture as an ATF. Four months after surgery, the fracture site exhibited bone fusion .\nUpon literature review, we discovered that only three previously reported cases of atypical tibia fracture with denosumab had been published. We searched the PubMed database for papers related to atypical tibia fractures and discovered 97 references. After checking all of the titles and abstracts, we found three reports of atypical tibia fractures related to denosumab use [–]. The results are shown in Table .\nIn one case, the patient had a giant cell tumor of the femur and was administered 120 mg denosumab once a month, the same dose as in this case. All three reports described bilateral tibial lesions. The patient in this study had no pain in the right tibia and no cortical thickness (beaking sign), as was observed in the X-ray images of her left tibia, in the right tibia. Informed consent for the acquisition of data to present in this case report was obtained during the hospitalization, and signed by the patient herself.", + "fulltext_subclaims": [ + "The patient was an 82-year-old Japanese woman.", + "She had received yearly intravenous denosumab for 4 years.", + "She presented with a fracture fulfilling the criteria for an atypical fracture, except for being located at the tibial diaphysis.", + "There was no history of bisphosphonate or oral glucocorticoid use.", + "She was found to have stage 4 breast cancer with multiple bone metastases 4 years prior.", + "She has been treated with an aromatase inhibitor and denosumab.", + "The patient had no obvious history of trauma.", + "One day, while walking, pain appeared in her left shin.", + "A few days after the pain occurred, she visited an outpatient orthopedic clinic.", + "X-ray images from the initial visit were obtained.", + "Her fracture was without any accompanying dislocation.", + "She was followed up at home with full weight bearing on her left leg.", + "Her pain persisted for a month after the initial visit.", + "She had difficulty walking because of the shin pain.", + "She returned to the orthopedic outpatient clinic.", + "X-ray images demonstrated a non-displaced transverse fracture of the proximal third of the left tibial diaphysis.", + "She had multiple bone metastases to several spinal and pelvic bones 4 years prior.", + "The tibial fracture was considered a differential for a pathological fracture due to a metastatic bone tumor.", + "The patient underwent additional imaging examination, including CT and MRI scans.", + "The CT and MRI images did not show any positive findings to suggest a metastatic bone tumor.", + "The CT and MRI images could not rule out the possibility of a metastatic bone tumor.", + "At the time of the fracture, the serum biochemical parameters of bone metabolism and cancer markers were 25-hydroxyvitamin D 32 ng/mL, total calcium 10.3 mg/dL, TRACP-5b 192 mU/dL, CEA 66.3 ng/mL, and CA15-3 109.7 U/mL.", + "Her tibial fracture pattern fulfilled all the major criteria (except for the location) and several minor criteria of an atypical fracture.", + "We suspected from these findings that her tibial fracture was atypical.", + "She had difficulty walking due to pain and underwent surgical treatment.", + "Treatment consisted of an intramedullary nail that immediately resolved the pain.", + "The cancellous bone within the medullary cavity of the fracture was harvested during intramedullary reaming.", + "The skin near the medial fracture site was also incised, and external periosteum and bone tissue around the fracture site were collected.", + "Pathological examinations were performed on both bone tissue samples.", + "Both samples had no neoplastic changes that could be considered breast cancer-associated bone metastases.", + "A pathological fracture due to bone metastases from breast cancer was ruled out.", + "We diagnosed her tibial fracture as an ATF.", + "Four months after surgery, the fracture site exhibited bone fusion.", + "Upon literature review, we discovered that only three previously reported cases of atypical tibia fracture with denosumab had been published.", + "We searched the PubMed database for papers related to atypical tibia fractures.", + "We found three reports of atypical tibia fractures related to denosumab use.", + "In one case, the patient had a giant cell tumor of the femur and was administered 120 mg denosumab once a month.", + "All three reports described bilateral tibial lesions.", + "The patient in this study had no pain in the right tibia.", + "Informed consent for the acquisition of data to present in this case report was obtained during the hospitalization.", + "Informed consent was signed by the patient herself." + ], + "summary": "We report here the case of an 82-year-old Japanese woman who had received yearly intravenous denosumab for 4 years and presented with a fracture fulfilling the criteria for an atypical fracture, except for being located at the tibial diaphysis. She was found to have stage 4 breast cancer with multiple bone metastases 4 years prior. She had difficulty walking due to her tibial pain and underwent surgical treatment. Four months after surgery, the tibial fracture site exhibited bone fusion.", + "summary_subclaims": [ + "The patient was an 82-year-old Japanese woman.", + "She had received yearly intravenous denosumab for 4 years.", + "She presented with a fracture fulfilling the criteria for an atypical fracture.", + "The fracture was located at the tibial diaphysis.", + "She was found to have stage 4 breast cancer with multiple bone metastases 4 years prior.", + "She had difficulty walking due to her tibial pain.", + "She underwent surgical treatment.", + "Four months after surgery, the tibial fracture site exhibited bone fusion." + ] + }, + { + "id": "multiclinsum_test_3338_en.txt", + "fulltext": "We present a case of a 93-year-old Middle Eastern male patient with no known food or drug allergies who was known to have hypothyroidism, hypertension, and dyslipidemia. The patient was admitted to the hospital owing to fatigue and refractory hiccups lasting for 2 weeks. He had had hiccups intermittently for more than 2 years and had tried several medications, including proton-pump inhibitors (PPIs), chlorpromazine, and baclofen, with minimal relief of his symptoms. His home medications include levothyroxine, amlodipine, and rosuvastatin. On review of systems, he denies dysphagia, odynophagia, food impaction, heartburn, vomiting, or weight loss. Physical examination was unremarkable. Laboratory studies were only pertinent for an elevated eosinophil count of 18% with a white blood cell count of 9000 per mL. Stool studies were negative for parasitic infection.\n\nImaging with computed tomography of the chest and abdomen was unremarkable. An upper endoscopy was subsequently performed and was normal, without any endoscopic finding to suggest EoE. Given his elevated peripheral eosinophil count, biopsies were taken from the mid- and distal esophagus and revealed eosinophilic infiltration in the range of 15 eosinophils per high-power field favoring a diagnosis of EoE.\n\nThe patient was prescribed a proton-pump inhibitor twice daily in combination with baclofen. Despite partial initial improvement, the symptoms of intractable hiccups recurred, and the decision was made to switch therapy to topical budesonide 2 mg twice daily 30 minutes before meals. The frequency of the hiccups episodes gradually decreased and resolved completely within a week. Repeat blood test showed a decrease in eosinophilic count to 10%. A repeat endoscopy was offered but declined by the patient.", + "fulltext_subclaims": [ + "The patient is a 93-year-old Middle Eastern male.", + "The patient has no known food or drug allergies.", + "The patient has hypothyroidism.", + "The patient has hypertension.", + "The patient has dyslipidemia.", + "The patient was admitted to the hospital owing to fatigue and refractory hiccups lasting for 2 weeks.", + "The patient had had hiccups intermittently for more than 2 years.", + "The patient had tried several medications, including proton-pump inhibitors, chlorpromazine, and baclofen, with minimal relief of his symptoms.", + "The patient's home medications include levothyroxine, amlodipine, and rosuvastatin.", + "The patient denies dysphagia, odynophagia, food impaction, heartburn, vomiting, or weight loss.", + "Physical examination was unremarkable.", + "Laboratory studies were only pertinent for an elevated eosinophil count of 18%.", + "Stool studies were negative for parasitic infection.", + "Imaging with computed tomography of the chest and abdomen was unremarkable.", + "An upper endoscopy was performed and was normal, without any endoscopic finding to suggest EoE.", + "Biopsies from the mid- and distal esophagus revealed eosinophilic infiltration in the range of 15 eosinophils per high-power field.", + "The diagnosis favored EoE.", + "The patient was prescribed a proton-pump inhibitor twice daily in combination with baclofen.", + "The symptoms of intractable hiccups recurred despite partial initial improvement.", + "The decision was made to switch therapy to topical budesonide 2 mg twice daily 30 minutes before meals.", + "The frequency of the hiccup episodes gradually decreased and resolved completely within a week.", + "Repeat blood test showed a decrease in eosinophilic count to 10%.", + "A repeat endoscopy was offered but declined by the patient." + ], + "summary": "We report a case of a 93-year-old Middle Eastern male presenting for longstanding treatment-refractory hiccups. Imaging with computed tomography of the chest and abdomen was unremarkable. An upper endoscopy was normal without any endoscopic finding to suggest eosinophilic esophagitis. Given his elevated peripheral eosinophil count, biopsies were taken from mid- and distal esophagus and revealed eosinophilic infiltration in the range of 15 eosinophils per high-power field, favoring a diagnosis of eosinophilic esophagitis. The hiccups resolved following the initiation of eosinophilic esophagitis treatment.", + "summary_subclaims": [ + "The patient is a 93-year-old Middle Eastern male.", + "The patient had longstanding treatment-refractory hiccups.", + "Computed tomography of the chest and abdomen was unremarkable.", + "An upper endoscopy was normal.", + "There were no endoscopic findings to suggest eosinophilic esophagitis.", + "The patient had an elevated peripheral eosinophil count.", + "Biopsies were taken from the mid- and distal esophagus.", + "The biopsies revealed eosinophilic infiltration in the range of 15 eosinophils per high-power field.", + "The diagnosis favored eosinophilic esophagitis.", + "The hiccups resolved following the initiation of eosinophilic esophagitis treatment." + ] + }, + { + "id": "multiclinsum_test_1449_en.txt", + "fulltext": "A 39-year-old, gravida 7, para 2, woman came to the local hospital with a complaint of lower abdominal dull pain for 3 h at 34 weeks’ gestation. Her obstetrical history began with two preterm spontaneous vaginal delivery (one at 28 weeks’ gestation; one at 30 weeks’ gestation) at the age of 18 and 19, respectively. Her third, fourth, and fifth pregnancies ended in abortion at early gestation with dilation & curettage treatment. In her previous pregnancy at 36 years of age, she received laparoscopic left salpingectomy and methotrexate (MTX) treatment due to ectopic pregnancy. No other surgeries on the pelvis or abdomen has been performed.\nHer general condition was stable. Physical examination showed normal secretions, no vaginal bleeding or fluid, no cervical dilation, but irregular preterm contractions with a shortened cervical length. Ultrasonography revealed a decreased amniotic fluid index (AFI 4.0 cm) and a single intrauterine pregnancy with breech presentation and positive fetal heart activity. The placenta was located on the anterior wall of the uterus. Laboratory tests were performed at the time of admission and did not show any significant findings, and hemoglobin level was 120 g/L. Due to the risk of premature birth, dydrogesterone was used to relieve uterine contraction and dexamethasone was administered to accelerate fetal lung maturation. Over 2 days following admission, her symptoms gradually worsened. She presented with diffuse abdominal pain and distension. She also reported nausea and had problem in defecating. Ultrasonography of the abdomen represented intestinal dilatation and multiple intestinal contents and air-fluid levels in the colon. Therefore, an intestinal obstruction was suspected. Enema was used to help intestinal peristalsis.\nAs there was no improvement in her condition, the patient requested a transfer to our hospital. Clinical examination revealed epigastric tenderness and mild abdominal distension, with no signs of guarding or peritonitis. Bowel sounds were weak. Consulting with the surgeon on duty, an abdominal computed tomography (CT) was performed after informed consent from the patient. CT represented dilatation of ascending colon and transverse colon . The symptoms were relieved after a nasogastric tube was inserted initially and enema was used. Since ultrasonography revealed oligohydramnios, a test for amniotic fluid crystal was performed, showing no signs of premature rupture of fetal membrane. On the fourth day following admission in our hospital, ultrasonography showed merely no fluid in the amniotic sac and the patient complained of no complete relief of bowel obstruction. Therefore, an emergency caesarean section (C-section) was performed. A healthy baby was delivered with no complications. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis and intestinal arrangement performed by a colon and rectal surgeon, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding . The uterine scar was repaired using a double-layer closure.\nRe-evaluation of the former abdominal CT was taken, revealing discontinuity of the uterine muscle layer in the left uterine cornua , which was consistent with intraoperative findings. Considering that the hemoglobin level didn’t decrease, her blood pressure remained stable, and no fetal distress happened during her labor of the birth, we assumed that the uterine rupture may occurred very early. Since omentum and colon were attached to the site of perforation, no clinical signs of uterine rupture were presented. As uterus enlarged, changes in the transit of intestinal tract decreased the intestinal peristalsis and then caused obstruction.\nThe patient recovered well without any complications and was discharged on the fifth postoperative day.", + "fulltext_subclaims": [ + "The patient is a 39-year-old woman.", + "She is gravida 7 and para 2.", + "She presented with lower abdominal dull pain for 3 h at 34 weeks’ gestation.", + "She had two preterm spontaneous vaginal deliveries at 28 and 30 weeks’ gestation.", + "Her third, fourth, and fifth pregnancies ended in early gestation abortions with dilation & curettage.", + "In her previous pregnancy, she had laparoscopic left salpingectomy and methotrexate treatment due to ectopic pregnancy.", + "No other surgeries on the pelvis or abdomen have been performed.", + "Physical examination showed no vaginal bleeding or fluid.", + "Ultrasonography revealed a decreased amniotic fluid index (AFI 4.0 cm).", + "The placenta was located on the anterior wall of the uterus.", + "Dydrogesterone was used to relieve uterine contraction.", + "Dexamethasone was administered to accelerate fetal lung maturation.", + "She developed diffuse abdominal pain and distension.", + "Ultrasonography showed intestinal dilatation and multiple air-fluid levels in the colon.", + "An intestinal obstruction was suspected.", + "An enema was used to help intestinal peristalsis.", + "An abdominal CT was performed after informed consent.", + "CT showed dilatation of ascending colon and transverse colon.", + "A nasogastric tube was inserted.", + "A test for amniotic fluid crystal showed no signs of premature rupture of fetal membrane.", + "An emergency caesarean section was performed.", + "A healthy baby was delivered with no complications.", + "Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon.", + "Uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found.", + "The uterine scar was repaired using a double-layer closure.", + "Re-evaluation of the former abdominal CT showed discontinuity of the uterine muscle layer in the left uterine cornua.", + "The patient was discharged on the fifth postoperative day." + ], + "summary": "We reported a 39-year old, gravida 7, para 2, woman who suffered from acute intestinal obstruction at 34 weeks of gestation. Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnose. Conservative treatment was initially attempted. But following ultrasound found the absence of fluid in the amniotic sac and the patient showed no improvement in clinical symptoms. An emergency caesarean section was then performed. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding. The uterine rupture was then repaired.", + "summary_subclaims": [ + "The patient was a 39-year old, gravida 7, para 2, woman.", + "She suffered from acute intestinal obstruction at 34 weeks of gestation.", + "Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnosis.", + "Conservative treatment was initially attempted.", + "Following ultrasound found the absence of fluid in the amniotic sac.", + "The patient showed no improvement in clinical symptoms.", + "An emergency caesarean section was then performed.", + "Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon.", + "After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding.", + "The uterine rupture was then repaired." + ] + }, + { + "id": "multiclinsum_test_1731_en.txt", + "fulltext": "A 50-year-old female with a history of well-controlled focal epilepsy presented to her neurologist with new symptoms of recurrent ‘sudden collapse’. At the age of 30, the patient had been diagnosed with non-lesional temporal lobe epilepsy characterized primarily by episodes of tonic–clonic seizures preceded by a sensation of déjà vu. She had been started on carbamazepine at that time with excellent seizure control. Her medical history was positive for hypertension and dyslipidaemia. She also maintained a family history of cardiac disease, unspecified. The patient had not suffered from any seizures or syncopal events until 5 months before her presentation. She complained of ‘unusual’ episodes, witnessed by her husband, of sudden drop attacks with brief loss of consciousness and postural tone associated with urinary incontinence. The syncopal episodes occurred without warning and without an associated trigger. She sustained no significant injuries from her syncopal events. Her clinical examination and biochemical profile on blood work were unremarkable. Magnetic resonance imaging of the head did not reveal evidence of acute changes to explain her presentation. Her carbamazepine dose was escalated in an attempt to control these episodes but failed to result in any improvement. Her antiepileptic medication was then changed from carbamazepine 200 mg p.o. t.i.d. to brivaracetam 75 mg p.o. b.i.d., again with no improvement. The patient underwent a continuous video-electroencephalographic study to characterize these events further.\nDuring observation in the epilepsy unit, the patient was observed to have an episode of sudden of loss of consciousness and urinary incontinence without any tonic–clonic activity or a prominent post-ictal state. Continuous electrocardiogram (ECG) monitoring revealed a concurrent episode of asystole lasting ∼20 s, followed by sinus bradycardia at a rate of 20–30 beats/min . There was no evidence of seizure activity on the electroencephalogram (EEG) preceding, during or following this event. The patient recovered and was subsequently admitted to the coronary care unit. On examination, her heart rate was 82 per minute, blood pressure was 128/74 mmHg, 86 kg, body mass index 32.1, and the systems examination was normal. She was recorded to have two episodes of symptomatic Mobitz type I atrioventricular (AV) block. Overall, her findings were consistent with isolated symptomatic bradyarrhythmia rather than ictal bradyarrhythmia or seizures. An echocardiogram was completed, which did not reveal any abnormalities. She underwent the successful implantation of a dual-chamber pacemaker. Her device was programmed to AAI-DDD with lower and upper rates of 50–130. Paced AV delay was set to 220 ms, and sensed AV delay 200 ms. Rate drop response was programmed ‘on’ to both low rate and rate drop. At 13-month follow-up, the patient was symptom free with no recurrence of her presenting events. Interrogation of her pacemaker revealed atrial pacing at 15.2% and ventricular pacing at 11%, suggesting a bradyarrhythmia of atrial aetiology.\nThe patient was maintained on brivaracetam as her antiepileptic and was well tolerated. A decision was made not to switch back to her original anticonvulsant, carbamazepine, despite the non-ictal aetiology of her event. Carbamazepine exerts its therapeutic function through sodium channel blockade and can therefore theoretically affect depolarization currents within cardiomyocytes. Its use has been reported by the Food and Drug Administration (FDA) to be associated with AV block. As such, given the patients bradyarrhythmia, she was maintained on the alternative agent.", + "fulltext_subclaims": [ + "The patient is a 50-year-old female.", + "She has a history of well-controlled focal epilepsy.", + "She presented with new symptoms of recurrent 'sudden collapse'.", + "She had been diagnosed with non-lesional temporal lobe epilepsy at the age of 30.", + "Her epilepsy was characterized by episodes of tonic–clonic seizures preceded by a sensation of déjà vu.", + "She had been started on carbamazepine at that time.", + "She had excellent seizure control with carbamazepine.", + "She had not suffered from any seizures or syncopal events until 5 months before her presentation.", + "She complained of 'unusual' episodes of sudden drop attacks with brief loss of consciousness and postural tone.", + "The syncopal episodes occurred without warning and without an associated trigger.", + "Her clinical examination and biochemical profile on blood work were unremarkable.", + "Magnetic resonance imaging of the head did not reveal evidence of acute changes.", + "Her carbamazepine dose was escalated in an attempt to control these episodes.", + "The dose escalation failed to result in any improvement.", + "Her antiepileptic medication was changed from carbamazepine 200 mg p.o. t.i.d. to brivaracetam 75 mg p.o. b.i.d.", + "The change to brivaracetam also resulted in no improvement.", + "The patient underwent a continuous video-electroencephalographic study.", + "During observation in the epilepsy unit, the patient was observed to have an episode of sudden loss of consciousness and urinary incontinence.", + "Continuous electrocardiogram monitoring revealed a concurrent episode of asystole lasting ∼20 s.", + "There was no evidence of seizure activity on the electroencephalogram preceding, during, or following the event.", + "The patient recovered and was admitted to the coronary care unit.", + "She was recorded to have two episodes of symptomatic Mobitz type I atrioventricular block.", + "Her findings were consistent with isolated symptomatic bradyarrhythmia.", + "An echocardiogram did not reveal any abnormalities.", + "She underwent the successful implantation of a dual-chamber pacemaker.", + "The pacemaker was programmed to AAI-DDD with lower and upper rates of 50–130.", + "At 13-month follow-up, the patient was symptom free with no recurrence of her presenting events.", + "Interrogation of her pacemaker revealed atrial pacing at 15.2% and ventricular pacing at 11%.", + "The patient was maintained on brivaracetam as her antiepileptic.", + "A decision was made not to switch back to her original anticonvulsant, carbamazepine.", + "Carbamazepine exerts its therapeutic function through sodium channel blockade.", + "Carbamazepine can theoretically affect depolarization currents within cardiomyocytes.", + "Its use has been reported by the Food and Drug Administration to be associated with AV block." + ], + "summary": "A 50-year-old female with well-controlled temporal epilepsy and a 20-year seizure-free period presented to her neurologist with abrupt onset of sudden drop attacks thought to be ictal events with potential underlying ictal bradyarrhythmia and was initially treated with escalation of anticonvulsant therapy. However, her workup was consistent with a diagnosis of cardiac syncope. She subsequently underwent successful insertion of a pacemaker, with no recurrence of her presenting episodes at a 13-month follow-up.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "She has well-controlled temporal epilepsy.", + "She has a 20-year seizure-free period.", + "She presented to her neurologist with abrupt onset of sudden drop attacks.", + "The sudden drop attacks were thought to be ictal events.", + "The sudden drop attacks were thought to have potential underlying ictal bradyarrhythmia.", + "She was initially treated with escalation of anticonvulsant therapy.", + "Her workup was consistent with a diagnosis of cardiac syncope.", + "She underwent successful insertion of a pacemaker.", + "She had no recurrence of her presenting episodes at a 13-month follow-up." + ] + }, + { + "id": "multiclinsum_test_3086_en.txt", + "fulltext": "We present a 22 year old male patient who presented with abdominal distension and vomiting of ingested matter of two to three episodes per day of one month duration. He has significant weight loss. He is a known schizophrenic patient for the past three years and has followed up at a nearby hospital, after which he has been off his medication for the past two months. He swallowed metallic nails in an attempt to kill himself. On presentation his vital signs were, blood pressure 110/70, pulse rate 128, respiratory rate 20, axillary temperature 36.5 and oxygen saturation 92%. On abdominal examination there was distension, epigastric tenderness and no signs of fluid collection. On admission his blood tests were, white blood count 15,000, hemoglobin 14 gm/dl, platelet 138,000 and granulocytes 77%. Serum electrolytes, random blood sugar and organ function tests (liver and renal) were in normal range. On the other hand, his plain abdominal x-ray showed multiple radiopaque foreign body namely nail in the stomach. Similarly, abdominal ultrasound showed thickened gastric wall and multiple linear foreign bodies in the stomach.\n\nEventually, with the impression of complete gastric outlet obstruction secondary to foreign body in the stomach, laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia. Intraoperative findings were dilated stomach, palpable mass on distal stomach and first part of duodenum, and adhesion between stomach, abdominal wall and liver. Subsequently, gastrotomy was made proximal to the foreign body area. Foreign bodies consisting of sixty curved, and straight nails of various sizes, needle and wire were removed with sponge forceps. Gastrotomy incision was repaired with two layers. Abdominal cavity was washed with warm normal saline. The abdominal incision was closed with two layers. The patient was then transferred to surgical ward with stable vital signs and put on antibiotics. Postoperative hematocrit was 36%. The patient was discharged after four days of hospital stay and linked to psychiatric department for further evaluation.", + "fulltext_subclaims": [ + "The patient is a 22 year old male.", + "He presented with abdominal distension and vomiting of ingested matter.", + "The vomiting occurred two to three episodes per day.", + "The symptoms lasted one month.", + "He has significant weight loss.", + "He is a known schizophrenic patient for the past three years.", + "He has been off his medication for the past two months.", + "He swallowed metallic nails in an attempt to kill himself.", + "On presentation, blood pressure was 110/70.", + "On presentation, pulse rate was 128.", + "On presentation, oxygen saturation was 92%.", + "On abdominal examination, there was distension.", + "On abdominal examination, there was epigastric tenderness.", + "Plain abdominal x-ray showed multiple radiopaque foreign bodies in the stomach.", + "Abdominal ultrasound showed thickened gastric wall.", + "The impression was complete gastric outlet obstruction secondary to foreign body in the stomach.", + "Laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia.", + "Intraoperative findings included a dilated stomach.", + "Intraoperative findings included a palpable mass on distal stomach and first part of duodenum.", + "Intraoperative findings included adhesion between stomach, abdominal wall and liver.", + "Foreign bodies consisting of sixty curved, and straight nails of various sizes, needle and wire were removed.", + "Gastrotomy incision was repaired with two layers.", + "The abdominal cavity was washed with warm normal saline.", + "The abdominal incision was closed with two layers.", + "The patient was transferred to surgical ward with stable vital signs.", + "The patient was put on antibiotics.", + "Postoperative hematocrit was 36%.", + "The patient was discharged after four days of hospital stay.", + "The patient was linked to psychiatric department for further evaluation." + ], + "summary": "We present a 22 year old male patient who presented with abdominal distension and vomiting of ingested matter of two to three episodes per day of one month duration. He is a known schizophrenic patient for the past three years and has been on follow up at a nearby hospital. He swallowed metallic nails in an attempt to kill himself. On abdominal examination there was distension, and epigastric tenderness. His plain abdominal x-ray showed multiple radiopaque foreign body in the stomach. Similarly, abdominal ultrasound showed thickened gastric wall and multiple linear foreign bodies in the stomach. Then, with the impression of gastric outlet obstruction secondary to foreign body in the stomach, laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia. Dilated stomach, palpable mass on distal stomach and first part of duodenum, and adhesion between stomach, abdominal wall and liver was found intra operatively.", + "summary_subclaims": [ + "The patient is a 22 year old male.", + "He presented with abdominal distension and vomiting of ingested matter.", + "The vomiting occurred two to three episodes per day.", + "The symptoms had a duration of one month.", + "He is a known schizophrenic patient.", + "He has been on follow up at a nearby hospital.", + "He swallowed metallic nails in an attempt to kill himself.", + "On abdominal examination there was distension.", + "There was epigastric tenderness.", + "The plain abdominal x-ray showed multiple radiopaque foreign bodies in the stomach.", + "The abdominal ultrasound showed thickened gastric wall.", + "The abdominal ultrasound showed multiple linear foreign bodies in the stomach.", + "The impression was gastric outlet obstruction secondary to foreign body in the stomach.", + "Laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia.", + "Dilated stomach was found intra operatively.", + "A palpable mass on distal stomach and first part of duodenum was found intra operatively.", + "Adhesion between stomach, abdominal wall and liver was found intra operatively." + ] + }, + { + "id": "multiclinsum_test_2640_en.txt", + "fulltext": "A 24-year-old (gravida 0 para 0) female without experience of sexual intercourse was referred to our gynecology department with complaints of menorrhagia and vaginal discharge. Physical examination revealed multiple hyperpigmented macules on her lips, buccal mucosa, fingertips, and toes . She was diagnosed with mild anemia at 10 years of age; genetic screening for thalassemia reported no abnormalities. At 15, she underwent a laparotomy to treat an “intestinal obstruction.” Since the age of 21 years, she has experienced a prolonged menstrual period (50–60 days) and hypermenorrhea, accompanied by a clean and odorless vaginal discharge. The US examination showed an enlarged cervix with multicystic lesions, the largest of which measured 1.9 cm×3.4 cm×2.2 cm. The patient has since experienced occasional hematochezia and was referred to several medical institutions to treat abnormal uterine bleeding. At 23 years of age, she underwent gastrointestinal endoscopy, revealing chronic non-atrophic gastritis and multiple polyps in the stomach, duodenum, and rectum. The pathological diagnosis of the resected polyp specimen from the mid-ileum revealed chronic active inflammation involving the superficial mucosa . During this period, the medical imaging examination revealed a growing cervical mass. Serum gynecological tumor markers, including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen (CA) 199 (CA199), CA153, and CA125, were within normal levels. The human papillomavirus screening test results for cervical secretions were negative. The patient’s father and younger brothers had similar black mucocutaneous macules, and her grandfather died of gastrointestinal bleeding. Except for her father, who was also diagnosed with leukoderma, the patient and her family denied the presence of other familial diseases.\nAfter admission to the inpatient department, the patient underwent magnetic resonance imaging (MRI) and multimodal US . Transrectal US revealed an enlarged, barrel-shaped cervix (6.4 cm×5.7 cm×6.0 cm) containing multilocular lesions of various sizes comprising a few solid components. The cervical lesions occupied almost the entire cervix, with the upper rim reaching the internal cervical os and the lower rim 0.7 cm above the external cervical os. No cervical myometrial echo was found. Some solid components were found in the septae between neighboring cysts, which altogether measure 4.0 cm×3.0 cm×3.3 cm; the cystic-solid echoes were encompassed by relatively larger cystic echoes. The cystic echoes, with diameters of 0.1–1.0 cm, were honeycomb-shaped with a slightly higher solid echo. The solid echo and septae showed strip-like rich blood flow signals with an arterial spectrum resistive index of 0.57. The cervical canal had a 0.4 cm separation, making the line of the cervical mucosa invisible. No abnormal echoes were observed in the anterior or posterior vaginal fornix or in the endometrium and myometrium of the uterus. No space-occupying lesions were observed in the uterine parametrium. An anechoic cyst, measuring 3.4 cm×2.3 cm×2.8 cm, was found in the left ovary. The ovarian cyst had a thin wall and was surrounded by a few short, strip-like blood flow signals. No lesions were observed in the right adnexa. The three-dimensional reconstructed view using 3D realisticVue (W10 EV3-10B, Samsung Medical, Seoul, South Korea) displayed multilocular lesions resembling the “cosmos pattern” in MRI examination, nearly occupying the whole cervix . Three-dimensional power Doppler US revealed an increased blood supply with irregular ramifications, parts of which multiplied and formed clump-like patterns. Three-dimensional tomographic US imaging of the blood flow of the cervical lesion indicated that its blood supply was located in the intercyst septae and solid components. The blood flow histograms revealed the following results: vascularization index, 4.567; flow index, 35.374; vascularization-flow index (VFI), 1.615. Using the VOCAL software (Voluson TM E10 BT19, General Electric Company, Boston, Massachusetts, the United States), the volume of the mass measured was 80.65 cm.3 Contrast-enhanced ultrasonography (CEUS) (PHILIPS EPIQ7, Philips Healthcare, Seattle, WA, the United States) using intravenous SonoVue (Bracco, Milan, Italia) revealed that solid components of the cervical mixed echo begun to develop at 7 s and peaked at 22.14 s, which gradually faded and presented a slightly increased signal in the final stage, exhibiting a “quick-up and slow-down” pattern of the time-intensity curve. CEUS also displayed a local density random walk wash-in/wash-out curve type with a wash-in slope of 1.62 dB/s, peak intensity of 19.03 dB, time from peak to 1/2 of 39.67 s, and mean transit time of 26.63 s. The cervical serous layer displayed continuous echoes of the signal, which did not increase simultaneously with the solid components of the cervical masses. The MRI revealed an enlarged cervix with multilocular space-occupying lesions of various sizes involving the entire muscular layer.\nSubsequently, a hysteroscopic biopsy revealed multiple polyp-like neoplasms in the uterine cavity and multilocular lesions in the cervix . Pathological examination of the biopsy specimen revealed LEGH and aLEGH. Whole-exome and Sanger sequencing confirmed the STK11 gene mutation in the patient and her family .\nBased on the evidence mentioned above, the patient was diagnosed with PJS and recommended undergoing laparoscopic exploration and cervicectomy according to clinical guidelines [, ]. The lesion-penetrated parts of the lower uterus, cervix, and ovarian cyst were resected and subjected to pathological examinations, revealing that the cervix and lower part of the uterus were both invaded by glandular lesions . Immunohistochemistry revealed Polyclonal Antibody to Mucin 6 (MUC6)-positivity. Simple gastric metaplasia (SGM) and LEGH in the cervix were also documented, suggesting the presence of gastric-type glandular epithelium. Alcian-blue/Periodic acid Schiff reagent (AB/PAS) staining revealed the presence of neutral mucus in the gastric-type cells.", + "fulltext_subclaims": [ + "The patient is a 24-year-old female.", + "She is gravida 0 para 0.", + "She has no experience of sexual intercourse.", + "She was referred to the gynecology department with menorrhagia and vaginal discharge.", + "Physical examination revealed multiple hyperpigmented macules on her lips, buccal mucosa, fingertips, and toes.", + "She was diagnosed with mild anemia at 10 years of age.", + "Genetic screening for thalassemia reported no abnormalities.", + "At 15 years of age, she underwent a laparotomy to treat an intestinal obstruction.", + "Since 21 years of age, she has experienced prolonged menstrual periods (50–60 days) and hypermenorrhea.", + "The US examination showed an enlarged cervix with multicystic lesions.", + "The largest cystic lesion measured 1.9 cm×3.4 cm×2.2 cm.", + "The patient has experienced occasional hematochezia.", + "She underwent gastrointestinal endoscopy at 23 years of age.", + "The endoscopy revealed chronic non-atrophic gastritis.", + "Multiple polyps were found in the stomach, duodenum, and rectum.", + "The pathological diagnosis of the resected ileal polyp was chronic active inflammation involving the superficial mucosa.", + "Medical imaging showed a growing cervical mass.", + "Serum gynecological tumor markers were within normal levels.", + "The human papillomavirus screening test for cervical secretions was negative.", + "The patient’s father and younger brothers had similar black mucocutaneous macules.", + "The patient’s grandfather died of gastrointestinal bleeding.", + "The patient’s father was diagnosed with leukoderma.", + "The patient and her family denied the presence of other familial diseases.", + "The patient underwent magnetic resonance imaging (MRI) and multimodal US.", + "Transrectal US revealed an enlarged, barrel-shaped cervix measuring 6.4 cm×5.7 cm×6.0 cm.", + "The cervical lesions occupied almost the entire cervix.", + "The upper rim of the cervical lesions reached the internal cervical os.", + "The lower rim was 0.7 cm above the external cervical os.", + "No cervical myometrial echo was found.", + "Some solid components were found in the septae between neighboring cysts, measuring 4.0 cm×3.0 cm×3.3 cm.", + "The cystic-solid echoes were encompassed by relatively larger cystic echoes.", + "The cystic echoes were honeycomb-shaped with a slightly higher solid echo.", + "The solid echo and septae showed strip-like rich blood flow signals.", + "The arterial spectrum resistive index was 0.57.", + "The cervical canal had a 0.4 cm separation.", + "The line of the cervical mucosa was invisible.", + "No abnormal echoes were observed in the anterior or posterior vaginal fornix.", + "No space-occupying lesions were observed in the uterine parametrium.", + "An anechoic cyst measuring 3.4 cm×2.3 cm×2.8 cm was found in the left ovary.", + "The ovarian cyst had a thin wall.", + "The ovarian cyst was surrounded by a few short, strip-like blood flow signals.", + "No lesions were observed in the right adnexa.", + "Three-dimensional power Doppler US revealed an increased blood supply with irregular ramifications.", + "Three-dimensional tomographic US imaging showed the blood supply was located in the intercyst septae and solid components.", + "The vascularization index was 4.567.", + "The flow index was 35.374.", + "The vascularization-flow index (VFI) was 1.615.", + "The volume of the mass measured 80.65 cm³.", + "Contrast-enhanced ultrasonography (CEUS) showed the solid components began to develop at 7 s.", + "The solid components peaked at 22.14 s.", + "The solid components exhibited a “quick-up and slow-down” pattern of the time-intensity curve.", + "CEUS displayed a local density random walk wash-in/wash-out curve type.", + "The wash-in slope was 1.62 dB/s.", + "The peak intensity was 19.03 dB.", + "The time from peak to 1/2 was 39.67 s.", + "The mean transit time was 26.63 s.", + "The cervical serous layer displayed continuous echoes of the signal.", + "The cervical serous layer did not increase simultaneously with the solid components.", + "MRI revealed an enlarged cervix with multilocular space-occupying lesions.", + "The lesions involved the entire muscular layer.", + "A hysteroscopic biopsy revealed multiple polyp-like neoplasms in the uterine cavity.", + "The biopsy also revealed multilocular lesions in the cervix.", + "Pathological examination of the biopsy specimen revealed LEGH and aLEGH.", + "Whole-exome and Sanger sequencing confirmed the STK11 gene mutation in the patient.", + "Whole-exome and Sanger sequencing confirmed the STK11 gene mutation in the patient’s family.", + "The patient was diagnosed with PJS.", + "The patient was recommended to undergo laparoscopic exploration and cervicectomy.", + "The lesion-penetrated parts of the lower uterus, cervix, and ovarian cyst were resected.", + "The resected specimens were subjected to pathological examinations.", + "The cervix and lower part of the uterus were both invaded by glandular lesions.", + "Immunohistochemistry revealed Polyclonal Antibody to Mucin 6 (MUC6)-positivity.", + "Simple gastric metaplasia (SGM) and LEGH in the cervix were documented.", + "Alcian-blue/Periodic acid Schiff reagent (AB/PAS) staining revealed the presence of neutral mucus in the gastric-type cells." + ], + "summary": "Here, we report a case of PJS in a 24-year-old female with multiple mucocutaneous black macules who complained of vaginal discharge and menorrhagia. Moreover, we first described the multimodal ultrasonographical manifestations of PJS-correlated G-EAC. The three-dimensional reconstructed view of G-EAC on 3D realisticVue exhibited a distinctive \"cosmos pattern\" resembling features on magnetic resonance imaging, and the contrast-enhanced ultrasound displayed a \"quick-up and slow-down\" pattern of the solid components inside the mixed cervical echoes. We reported the multimodal ultrasonographical characteristics of a case of PJS-related G-EAC, as well as reviewed PJS-related literature and medical imaging features and clinical characteristics of G-EAC to provide insight into the feasibility and potential of utilizing multimodal ultrasonography for the diagnosis of G-EAC.", + "summary_subclaims": [ + "The patient was a 24-year-old female.", + "The patient had multiple mucocutaneous black macules.", + "The patient complained of vaginal discharge.", + "The patient complained of menorrhagia.", + "The case reported first described multimodal ultrasonographical manifestations of PJS-correlated G-EAC.", + "The 3D realisticVue showed a distinctive 'cosmos pattern' resembling MRI features.", + "The contrast-enhanced ultrasound displayed a 'quick-up and slow-down' pattern of the solid components inside the mixed cervical echoes.", + "The multimodal ultrasonographical characteristics of a case of PJS-related G-EAC were reported.", + "The literature on PJS-related medical imaging features and clinical characteristics of G-EAC was reviewed.", + "The report aimed to provide insight into the feasibility and potential of utilizing multimodal ultrasonography for the diagnosis of G-EAC." + ] + }, + { + "id": "multiclinsum_test_1811_en.txt", + "fulltext": "This study involved a 62-year-old male who had undergone scleral buckling surgery 40 or more years ago for rhegmatogenous retinal detachment, as well as trabeculectomy 20 years ago for primary open-angle glaucoma in his left eye at another hospital. He presented to our hospital complaining of blurred vision in that eye. The patient reported that although the previous retinal reattachment surgery had resulted in a favorable outcome, he had experienced persistent conjunctival hyperemia, conjunctival edema, and low levels of ptosis during the subsequent recovery period. He reported that he had recently become aware of blurred vision in his left eye and subsequently consulted a local doctor. Upon examination at that facility, iritis and proliferating changes in the fundus had been identified in that eye, and he had been referred to our hospital.\nUpon examination, his visual acuity was 1.0 × S-3.5D C-1.5D A × 30° OD and 0.5p × S + 2.0D C-2.25D A × 160° OS, and his intraocular pressure was 20 mm Hg OD and 11 mm Hg OS. Iritis was observed in the anterior chamber of the left eye, as well as a great number of pigment cell keratoprecipitates on the posterior surface of the cornea . Minor cataracts were observed beneath the posterior capsule, and mydriasis was somewhat poor. In the ocular fundus of the left eye, extensive atrophy of the retinal pigment epithelium and partial hyperpigmentation were observed, accompanied by subretinal strands, yet the retina remained reattached. Around the entire peripheral area of the retina we observed a high, ring-shaped protrusion, but we also saw a shiny, filamentous material in the vitreous cavity that penetrated the sclera and choroid, completely extending from the 4- to 8-o'clock position of the protrusion . During a B-mode ultrasound scan, we observed a high-luminance image on the edge of the buckle protrusion with an acoustic shadow . We also observed slight opacity and inflammatory cells in the vitreous cavity. Thus, we diagnosed this patient as a case of intraocular erosion and intrusion by an Arruga suture, and for the iritis in the left eye we began to administrate low-concentration steroid eye drops, after which the inflammation disappeared. A previous doctor had performed a trabeculectomy on the left eye 20 years previously to treat primary open-angle glaucoma, and we recognized a filtration bleb in the upper part of the corneal limbus, but we saw no particular abnormalities in the middle optic media or fundus in the right eye.", + "fulltext_subclaims": [ + "The patient is a 62-year-old male.", + "He had undergone scleral buckling surgery 40 or more years ago for rhegmatogenous retinal detachment.", + "He had undergone trabeculectomy 20 years ago for primary open-angle glaucoma in his left eye at another hospital.", + "He presented to our hospital complaining of blurred vision in his left eye.", + "The patient reported that the previous retinal reattachment surgery had resulted in a favorable outcome.", + "He had experienced persistent conjunctival hyperemia, conjunctival edema, and low levels of ptosis during the subsequent recovery period.", + "He had recently become aware of blurred vision in his left eye and consulted a local doctor.", + "Upon examination at that facility, iritis and proliferating changes in the fundus had been identified in that eye.", + "He had been referred to our hospital.", + "His visual acuity was 1.0 × S-3.5D C-1.5D A × 30° OD.", + "His visual acuity was 0.5p × S + 2.0D C-2.25D A × 160° OS.", + "His intraocular pressure was 20 mm Hg OD.", + "His intraocular pressure was 11 mm Hg OS.", + "Iritis was observed in the anterior chamber of the left eye.", + "A great number of pigment cell keratoprecipitates were observed on the posterior surface of the cornea.", + "Minor cataracts were observed beneath the posterior capsule.", + "Mydriasis was somewhat poor.", + "In the ocular fundus of the left eye, extensive atrophy of the retinal pigment epithelium and partial hyperpigmentation were observed.", + "Subretinal strands were observed.", + "The retina remained reattached.", + "A high, ring-shaped protrusion was observed around the entire peripheral area of the retina.", + "A shiny, filamentous material was observed in the vitreous cavity that penetrated the sclera and choroid.", + "The filamentous material completely extended from the 4- to 8-o'clock position of the protrusion.", + "During a B-mode ultrasound scan, a high-luminance image was observed on the edge of the buckle protrusion with an acoustic shadow.", + "Slight opacity and inflammatory cells were observed in the vitreous cavity.", + "We diagnosed this patient as a case of intraocular erosion and intrusion by an Arruga suture.", + "For the iritis in the left eye, we began to administer low-concentration steroid eye drops.", + "The inflammation disappeared.", + "A previous doctor had performed a trabeculectomy on the left eye 20 years previously to treat primary open-angle glaucoma.", + "We recognized a filtration bleb in the upper part of the corneal limbus.", + "We saw no particular abnormalities in the middle optic media or fundus in the right eye." + ], + "summary": "This study involved a 62-year-old male who had undergone scleral buckling surgery 40 or more years ago at another hospital for rhegmatogenous retinal detachment, as well as trabeculectomy 20 years ago for primary open-angle glaucoma, in his left eye at the same hospital. However, he recently became aware of blurred vision in that eye. Upon examination, iritis was observed in the anterior portion of his left eye, as well as a great number of pigment cell keratoprecipitates on the posterior surface of the cornea. In the ocular fundus, extensive atrophy of the retinal pigment epithelium and partial hyperpigmentation was observed, accompanied by subretinal strands, yet the retina remained attached. Around the entire peripheral area of the retina we observed a ring-shaped protrusion, but we also saw a shiny, filamentous material in the vitreous cavity that penetrated the sclera and choroid, completely extending from the 4- to 8-o'clock position of the scleral buckle protrusion. To treat the iritis in the patient's left eye, we began to administrate low-concentration steroid eye drops, after which the inflammation disappeared.", + "summary_subclaims": [ + "The patient is a 62-year-old male.", + "The patient had undergone scleral buckling surgery 40 or more years ago at another hospital.", + "The scleral buckling surgery was performed for rhegmatogenous retinal detachment.", + "The patient had trabeculectomy 20 years ago for primary open-angle glaucoma.", + "The trabeculectomy was performed in his left eye.", + "The patient recently became aware of blurred vision in his left eye.", + "Iritis was observed in the anterior portion of his left eye.", + "A great number of pigment cell keratoprecipitates were observed on the posterior surface of the cornea.", + "Extensive atrophy of the retinal pigment epithelium was observed in the ocular fundus.", + "Partial hyperpigmentation was observed in the ocular fundus.", + "Subretinal strands were observed.", + "The retina remained attached.", + "A ring-shaped protrusion was observed around the entire peripheral area of the retina.", + "A shiny, filamentous material was observed in the vitreous cavity.", + "The shiny, filamentous material extended from the 4- to 8-o'clock position of the scleral buckle protrusion.", + "The shiny, filamentous material completely extended from the 4- to 8-o'clock position of the scleral buckle protrusion.", + "Low-concentration steroid eye drops were administered to treat the iritis in the patient's left eye.", + "The inflammation disappeared after administration of low-concentration steroid eye drops." + ] + }, + { + "id": "multiclinsum_test_1181_en.txt", + "fulltext": "A 37-year-old woman with a history of chronic back pain and sciatica presented to our teaching hospital at 36.5 weeks' gestation in early labor. At the time of presentation, she was noted to have acute onset of mild-range elevated blood pressures (140s-150s/90s) with a urine protein-to-creatinine ratio of 0.37, consistent with a diagnosis of preeclampsia. Six hours after admission, her blood pressures progressed to severe-range, with a maximum of 195/105. Per protocol, she was given IV labetalol and MgSO4 for preeclampsia with severe features. Shortly thereafter, the patient retrospectively reported that she began to have mid-back pain along with numbness, tingling, and weakness in her right lower extremity, but she did not report these symptoms initially to her healthcare team, as she was more concerned about her pelvic pain with contractions. Approximately 3 hours after the onset of her neurological symptoms, a labor epidural was administered to help control her contraction pain and blood pressures. The epidural catheter was placed uneventfully at L3-L4 with the tip threaded to the maximum height of T11. As the epidural was being placed, the patient then reported to the anesthesiologist that she had been feeling weak. The patient was noted to appear lethargic on exam, but she was able to sit up with minimal assistance for her labor epidural. Therefore, her weakness was attributed to labor. She progressed to complete cervical dilation and had a vaginal delivery with vacuum assistance due to a 5-minute prolonged deceleration on FHT.\nThe patient continued to complain of leg weakness after delivery. At 14 hours postpartum, the nurse encouraged the patient to attempt ambulation. However, even with her best efforts, the patient was unable to move her body from a distinct line below her breasts down to her toes. She also noticed numbness, burning, and electrical sensations to light touch from that line down to her toes. At this time the resident team was notified, and a Foley catheter was inserted. There was low suspicion for magnesium toxicity as she had intact reflexes with no complaints of shortness of breath, and her magnesium level was 5.9. She still had mild-range elevated blood pressures at the time, and she remained on IV magnesium for 24 hours postpartum.\nA stat CT scan of the head without contrast resulted in normal findings with no evidence of stroke. MRI of the spine showed a fluid sac suggestive of epidural blood, measuring 3.5 cm in the craniocaudal plane and 0.4 cm in the anteroposterior plane. There was also a mild-to-moderate degree of spinal stenosis at T5-T6 due to extrinsic mass effect of the epidural hemorrhage but no direct spinal cord compression . The patient was immediately started on IV dexamethasone 4 mg q6h. Upon evaluation by neurosurgery, the patient was not considered to be a surgical candidate because the MRI showed no clear evidence of spinal cord hemorrhage or spinal cord compression.\nOn the morning of postpartum day #1, the patient remained with paresthesia in her lower extremities and flaccid paralysis from the waist down, but she was able to wiggle her toes. Her blood pressures were predominately normal (120-140/80-90) with a few mild-range elevated blood pressures. Per protocol, she was kept on IV magnesium for seizure prophylaxis until she was 24 hours postpartum. Diffusion-weighted imaging of the spine later that day showed an epidural lesion with a hemosiderin ring that had decreased in size to 2-3 mm in maximal depth, suggestive of a resolving epidural hematoma when compared to the most recent MRI .\nOn postpartum day #2, the patient was started on PO nifedipine XL 30 mg daily to consistently maintain her blood pressures within normal range. Her mobility improved with demonstrated flexion and extension at the hips bilaterally, in addition to return of normal sensation in her lower extremities.\nThe patient's movements and sensation continued to improve day by day while she was kept on IV dexamethasone and PO nifedipine. By postpartum day #4, the patient was ambulating with a walker and had good bladder and bowel control. On postpartum day #6, the patient was ambulating without assistance and reported complete resolution of her pain in the back and lower extremities. She was discharged home in stable condition.\nA follow-up MRI 6 weeks later showed complete resolution of the spinal epidural hematoma . At the time, she was still ambulating independently and had full control of her bladder and bowel function.", + "fulltext_subclaims": [ + "The patient was a 37-year-old woman with a history of chronic back pain and sciatica.", + "She presented at 36.5 weeks' gestation in early labor.", + "At presentation, she had acute onset of mild-range elevated blood pressures (140s-150s/90s).", + "Her urine protein-to-creatinine ratio was 0.37.", + "The diagnosis was preeclampsia.", + "Six hours after admission, her blood pressures progressed to severe-range, with a maximum of 195/105.", + "She was given IV labetalol and MgSO4 for preeclampsia with severe features.", + "She reported mid-back pain, numbness, tingling, and weakness in her right lower extremity.", + "She did not report these symptoms initially to her healthcare team.", + "Approximately 3 hours after the onset of her neurological symptoms, a labor epidural was administered.", + "The epidural catheter was placed uneventfully at L3-L4.", + "The epidural catheter tip was threaded to the maximum height of T11.", + "The patient reported feeling weak as the epidural was being placed.", + "She was noted to appear lethargic on exam.", + "She was able to sit up with minimal assistance for her labor epidural.", + "Her weakness was attributed to labor.", + "She progressed to complete cervical dilation and had a vaginal delivery with vacuum assistance.", + "The delivery occurred due to a 5-minute prolonged deceleration on fetal heart tones.", + "The patient continued to complain of leg weakness after delivery.", + "At 14 hours postpartum, the nurse encouraged the patient to attempt ambulation.", + "The patient was unable to move her body from a distinct line below her breasts down to her toes.", + "She noticed numbness, burning, and electrical sensations to light touch from that line down to her toes.", + "A Foley catheter was inserted.", + "There was low suspicion for magnesium toxicity.", + "She had intact reflexes with no complaints of shortness of breath.", + "Her magnesium level was 5.9.", + "She remained on IV magnesium for 24 hours postpartum.", + "A stat CT scan of the head without contrast resulted in normal findings.", + "MRI of the spine showed a fluid sac suggestive of epidural blood.", + "The epidural blood measured 3.5 cm in the craniocaudal plane.", + "The epidural blood measured 0.4 cm in the anteroposterior plane.", + "There was mild-to-moderate spinal stenosis at T5-T6 due to extrinsic mass effect of the epidural hemorrhage.", + "There was no direct spinal cord compression.", + "She was immediately started on IV dexamethasone 4 mg q6h.", + "Upon evaluation by neurosurgery, the patient was not considered a surgical candidate.", + "The MRI showed no clear evidence of spinal cord hemorrhage.", + "The MRI showed no spinal cord compression.", + "On postpartum day #1, the patient remained with paresthesia in her lower extremities.", + "She had flaccid paralysis from the waist down.", + "She was able to wiggle her toes.", + "Her blood pressures were predominately normal (120-140/80-90).", + "She was kept on IV magnesium for seizure prophylaxis until 24 hours postpartum.", + "Diffusion-weighted imaging of the spine showed an epidural lesion with a hemosiderin ring.", + "The lesion had decreased in size to 2-3 mm in maximal depth.", + "The lesion was suggestive of a resolving epidural hematoma.", + "On postpartum day #2, she was started on PO nifedipine XL 30 mg daily.", + "Her mobility improved with demonstrated flexion and extension at the hips bilaterally.", + "She had return of normal sensation in her lower extremities.", + "By postpartum day #4, the patient was ambulating with a walker.", + "She had good bladder and bowel control.", + "On postpartum day #6, the patient was ambulating without assistance.", + "She reported complete resolution of her pain in the back and lower extremities.", + "She was discharged home in stable condition.", + "A follow-up MRI 6 weeks later showed complete resolution of the spinal epidural hematoma.", + "At 6 weeks postpartum, she was ambulating independently.", + "She had full control of her bladder and bowel function." + ], + "summary": "We present the case of a 37-year-old pregnant woman with preeclampsia with severe features who developed neurological deficits that were initially attributed to her epidural anesthesia. She was eventually found to have SEH with spinal stenosis at T5-T6 on MRI. Oral antihypertensives were used to keep the patient's blood pressures within normal limits, and she subsequently had complete resolution of her neurological symptoms and her SEH on imaging.", + "summary_subclaims": [ + "The patient was a 37-year-old pregnant woman.", + "She had preeclampsia with severe features.", + "She developed neurological deficits.", + "The neurological deficits were initially attributed to her epidural anesthesia.", + "MRI showed SEH with spinal stenosis at T5-T6.", + "Oral antihypertensives were used to keep the patient's blood pressures within normal limits.", + "The patient had complete resolution of her neurological symptoms.", + "The patient had complete resolution of her SEH on imaging." + ] + }, + { + "id": "multiclinsum_test_3333_en.txt", + "fulltext": "62-year-old male, ex-smoker, with a history of hypertension, diabetes mellitus, and a pulmonary lobectomy for a moderately differentiated squamous carcinoma, with a negative positron emission tomography (PET) scan for distant disease and postoperative N2 staging, on neoadjuvant treatment with carboplatin and docetaxel. He presented to the emergency department on day 9 of the first cycle of chemotherapy with sudden abdominal pain in the right flank and iliac fossa associated with two days of diarrhea and fever. On physical examination, he presented tachycardia (105 beats per min), generalized tremors, and fever (38°C axillary). The abdominal examination revealed distension, pain on palpation in the right hemi-abdomen, with defense and peritoneal reaction.\n\nLaboratory tests included a complete blood count with a hemoglobin of 9.1 g/dL and 600 leukocytes/mm3, with 93% lymphocytes and critical neutropenia. An abdominal ultrasound with a focused abdominal sonography for trauma (FAST) protocol showed a small amount of free fluid in the pelvis. After taking blood cultures, empirical antibacterial therapy with piperacillin/tazobactam and amikacin was initiated.\n\nAn abdominal and pelvic CT scan with intravenous contrast was requested, which demonstrated a marked circumferential thickening of the walls of the cecum with an apparent break in continuity at the free edge and adjacent laminar fluid with air bubbles consistent with a contained intestinal perforation.\n\nHe underwent an emergency exploratory laparotomy and a 2 x 2 cm ischemic area cecal perforation and secondary peritonitis were found. A right hemicolectomy and a terminal ileostomy were performed. The histopathological study of the colon biopsy revealed the presence of an adenocarcinoma of the ring-like cells (high grade) associated with ischemia.\n\nThe patient died of sepsis progression 24 hours after surgery.\n", + "fulltext_subclaims": [ + "The patient is a 62-year-old male.", + "He is an ex-smoker.", + "He has a history of hypertension.", + "He has a history of diabetes mellitus.", + "He had a pulmonary lobectomy for a moderately differentiated squamous carcinoma.", + "He had a negative positron emission tomography (PET) scan for distant disease.", + "He had postoperative N2 staging.", + "He received neoadjuvant treatment with carboplatin and docetaxel.", + "He presented to the emergency department on day 9 of the first cycle of chemotherapy.", + "He had sudden abdominal pain in the right flank and iliac fossa.", + "He had two days of diarrhea.", + "He had fever.", + "On physical examination, he had tachycardia (105 beats per min).", + "On physical examination, he had generalized tremors.", + "On physical examination, he had fever (38°C axillary).", + "The abdominal examination revealed distension.", + "The abdominal examination revealed pain on palpation in the right hemi-abdomen.", + "The abdominal examination revealed defense.", + "The abdominal examination revealed peritoneal reaction.", + "The complete blood count showed a hemoglobin of 9.1 g/dL.", + "The complete blood count showed 600 leukocytes/mm3.", + "The complete blood count showed 93% lymphocytes.", + "The complete blood count showed critical neutropenia.", + "An abdominal ultrasound with a focused abdominal sonography for trauma (FAST) protocol showed a small amount of free fluid in the pelvis.", + "Empirical antibacterial therapy with piperacillin/tazobactam and amikacin was initiated.", + "An abdominal and pelvic CT scan with intravenous contrast was requested.", + "The CT scan demonstrated a marked circumferential thickening of the walls of the cecum.", + "The CT scan showed an apparent break in continuity at the free edge of the cecum.", + "The CT scan showed adjacent laminar fluid with air bubbles.", + "The CT scan findings were consistent with a contained intestinal perforation.", + "An emergency exploratory laparotomy was performed.", + "A 2 x 2 cm ischemic area cecal perforation was found.", + "Secondary peritonitis was found.", + "A right hemicolectomy was performed.", + "A terminal ileostomy was performed.", + "The histopathological study of the colon biopsy revealed the presence of an adenocarcinoma of the ring-like cells (high grade).", + "The histopathological study of the colon biopsy showed the presence of ischemia.", + "The patient died of sepsis progression 24 hours after surgery." + ], + "summary": "We present the case of a 62-year-old man who presented with abdominal pain, diarrhea and fever. A computed tomography of the abdomen and pelvis showed a thickening of the walls of the cecum with an apparent break in continuity at the free edge. An exploratory laparotomy confirmed the presence of peritonitis and cecal perforation, and the patient underwent a right hemicolectomy and a terminal ileostomy. The histopathological study revealed the presence of an adenocarcinoma of the ring-like cells type associated with ischemia. The blood cultures were positive for C. septicum. The patient died of a fulminant sepsis.\n", + "summary_subclaims": [ + "The patient was a 62-year-old man.", + "The patient presented with abdominal pain.", + "The patient presented with diarrhea.", + "The patient presented with fever.", + "A computed tomography of the abdomen and pelvis showed a thickening of the walls of the cecum.", + "The computed tomography showed an apparent break in continuity at the free edge.", + "An exploratory laparotomy confirmed the presence of peritonitis.", + "An exploratory laparotomy confirmed the presence of cecal perforation.", + "The patient underwent a right hemicolectomy.", + "The patient underwent a terminal ileostomy.", + "The histopathological study revealed the presence of an adenocarcinoma of the ring-like cells type.", + "The histopathological study revealed the presence of ischemia.", + "The blood cultures were positive for C. septicum.", + "The patient died of a fulminant sepsis." + ] + }, + { + "id": "multiclinsum_test_1892_en.txt", + "fulltext": "An 11-year-old male referred to the outpatient Department of Otorhinolaryngology with a complaint of throat irritation and hoarseness of voice over the past 3 months. He had no history of breathing difficulty, dysphagia, upper respiratory tract contamination, voice misuse, tobacco use, and previous radiation presentation. Moreover, there was no family history of head and neck malignancy or any hereditary variation from the norm related to the improvement of laryngeal carcinoma in youth.His past medical history was unremarkable. Indirect laryngoscopy revealed a growth in the left vocal cord. Fiberoptic nasopharyngolaryngoscopy showed an irregular growth in the left vocal cord with impaired cord mobility . There was no supraglottic and subglottic extension of the growth and swollen lymph node in neck. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the neck showed enhancement in the left vocal cord; moreover, other parts of the neck were within normal limit .\nFurthermore, no invasion or extralaryngeal spread to laryngeal cartilages was observed in this case report. In addition, thoracic CT scan was not indicative of distant metastasis. A biopsy was done under general anesthesia and histopathological examination showed moderately differentiated non-keratinizing squamous cell carcinoma .\nIt was inferred that the child had stage 1 glottic cancer (i.e., T1N0M0). Given the early stage of this disease, the patient was subjected to radiotherapy. After the fulfillment of radiotherapy, larynx was again inspected with no proof of lesion after 3 months . The patient did not require tracheostomy due to the treatment of laryngeal carcinoma and satisfactory laryngotracheal airway.", + "fulltext_subclaims": [ + "An 11-year-old male was referred to the outpatient Department of Otorhinolaryngology.", + "The patient had a complaint of throat irritation and hoarseness of voice over the past 3 months.", + "He had no history of breathing difficulty.", + "He had no history of dysphagia.", + "He had no history of upper respiratory tract contamination.", + "He had no history of voice misuse.", + "He had no history of tobacco use.", + "He had no previous radiation presentation.", + "There was no family history of head and neck malignancy.", + "There was no hereditary variation from the norm related to the improvement of laryngeal carcinoma in youth.", + "His past medical history was unremarkable.", + "Indirect laryngoscopy revealed a growth in the left vocal cord.", + "Fiberoptic nasopharyngolaryngoscopy showed an irregular growth in the left vocal cord with impaired cord mobility.", + "There was no supraglottic extension of the growth.", + "There was no subglottic extension of the growth.", + "There was no swollen lymph node in the neck.", + "Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the neck showed enhancement in the left vocal cord.", + "Other parts of the neck were within normal limits.", + "No invasion or extralaryngeal spread to laryngeal cartilages was observed.", + "Thoracic CT scan was not indicative of distant metastasis.", + "A biopsy was done under general anesthesia.", + "Histopathological examination showed moderately differentiated non-keratinizing squamous cell carcinoma.", + "It was inferred that the child had stage 1 glottic cancer (i.e., T1N0M0).", + "The patient was subjected to radiotherapy.", + "After the fulfillment of radiotherapy, larynx was again inspected with no proof of lesion after 3 months.", + "The patient did not require tracheostomy due to the treatment of laryngeal carcinoma." + ], + "summary": "An 11-year-old male presented with hoarseness of voice over the last 3 month and was diagnosed with laryngeal carcinoma based on the fiberoptic nasopharyngolaryngoscopy examinations and biopsy. He was treated with a complete course of radiotherapy.", + "summary_subclaims": [ + "The patient is an 11-year-old male.", + "The patient had hoarseness of voice over the last 3 months.", + "The patient was diagnosed with laryngeal carcinoma.", + "The diagnosis was based on fiberoptic nasopharyngolaryngoscopy examinations.", + "The diagnosis was based on biopsy.", + "The patient was treated with a complete course of radiotherapy." + ] + }, + { + "id": "multiclinsum_test_432_en.txt", + "fulltext": "The patient was a 60-year-old male who regularly visited a general practitioner for type 2 diabetes, who performed routine examination to rule out malignant disease. As his serum carbohydrate antigen 19-9 (CA 19-9) level was slightly elevated, abdominal CT was performed, which revealed a unilocular cystic mass of 8.0 cm in diameter, located in the lower right retroperitoneum. He was, therefore, referred to our hospital for surgical treatment.\nThe patient had no relevant family history or past history of malignant disease in the abdomen or retroperitoneum. He was asymptomatic and in good health, with the exception of severe obesity with a body mass index of 40. An abdominal examination revealed no tenderness or palpable mass. Laboratory findings showed a high hemoglobin A1c level (7%; normal range 0–6%). The increased serum CA 19-9 levels, which was 43.3 U/mL in the previous hospital, had normalized to 16.9 U/mL at the time of the examination at our hospital. Ultrasonography identified a uniform hypoechoic cystic mass without septum and calcification in the retroperitoneum adjacent to the end of the ileum and appendix, which indicated a hyperechoic region with a debris-like appearance and no obvious nodular lesions or blood flow in the cyst. On enhanced CT, the retroperitoneal cystic mass appeared to be close to the appendix on the ventral side and to the right gonadal vessel on the medial side . Non-enhanced CT was regularly performed by his general practitioner who was managing him or diabetes to rule out a pancreatic lesion, and we also observed the changes of this cystic lesion over the course of three and a half years . The first image showed that the lesion was a 5 cm cystic mass with a uniform high density, with a CT value of 101 Hounsfield Units (HU). The second image, obtained 3 years later, showed that the cystic lesion had grown to 8 cm and that the internal density had decreased, as CT value of 28 HU. Eventually, the cyst diameter increased further to reach 10 cm and the CT value decreased slightly to 20 HU. Based on these clinical findings and the location, retroperitoneal lymphangioma, dermoid cyst and mucinous cystadenoma of appendix were listed as differential diagnoses. After we informed the patient that it would be difficult to make an accurate diagnosis of the retroperitoneal lesion and that malignant transformation could not be denied as a reason for the enlargement, we planned surgical resection rather than careful follow-up.\nLaparoscopic surgery was performed under general anesthesia. The operative procedure began with the insertion of a 1.2 cm umbilical port using Hasson’s technique. Four additional ports were then inserted under direct visualization . The large cystic mass was identified in the retroperitoneal space below the right kidney and firmly adhered to the appendix and mesentery via the retroperitoneum . Due to strong adhesion, the appendix was dissected with a linear stapler and resected en bloc with the cystic lesion . After the lesion was mobilized from the retroperitoneal connective tissue, some feeding vessels from the right gonadal vessel were clipped and cut . The lesion was not associated with the colonic wall or ureter and could be completely dissected without injury to the surrounding organs. The lesion was placed in an entrapment endobag and removed from the abdomen via the umbilical port site. The total operative time was 157 min, and the estimated blood loss was small. Postoperatively, the patient made an uneventful recovery and was discharged home on postoperative day 4.\nThe resected specimens consisted of a unilocular cystic tumor of 10 cm in maximum diameter with a smooth inner surface and the appendix . The cystic lesion included a large amount of yellow, turbid serous fluid . Microscopically, hematoxylin and eosin staining demonstrated the smooth muscular layers in the cystic wall, which was consistent with the muscularis mucosae, submucosa and muscularis propria of the gastrointestinal tract without communication with the appendix . Desmin staining confirmed the intestinal wall structure of the muscularis mucosae and the muscularis propria, which are needed to make histological diagnosis of EDC . The lining epithelial cells were positive for Mucin 2, indicating an intestinal-type glandular mucosa . The final pathological diagnosis was IEDC in the retroperitoneal space. There was no histological evidence of malignancy.", + "fulltext_subclaims": [ + "The patient was a 60-year-old male.", + "He regularly visited a general practitioner for type 2 diabetes.", + "The general practitioner performed routine examination to rule out malignant disease.", + "His serum carbohydrate antigen 19-9 (CA 19-9) level was slightly elevated.", + "Abdominal CT revealed a unilocular cystic mass of 8.0 cm in diameter.", + "The cystic mass was located in the lower right retroperitoneum.", + "He was referred to our hospital for surgical treatment.", + "He had no relevant family history of malignant disease in the abdomen or retroperitoneum.", + "He had no past history of malignant disease in the abdomen or retroperitoneum.", + "He was asymptomatic.", + "He had a body mass index of 40.", + "An abdominal examination revealed no tenderness or palpable mass.", + "The hemoglobin A1c level was 7%.", + "The serum CA 19-9 level had normalized to 16.9 U/mL at the time of the examination at our hospital.", + "Ultrasonography identified a uniform hypoechoic cystic mass without septum and calcification.", + "The cyst was adjacent to the end of the ileum and appendix.", + "The cyst showed a hyperechoic region with a debris-like appearance.", + "There were no obvious nodular lesions or blood flow in the cyst.", + "On enhanced CT, the cystic mass was close to the appendix on the ventral side.", + "On enhanced CT, the cystic mass was close to the right gonadal vessel on the medial side.", + "Non-enhanced CT was regularly performed by his general practitioner.", + "The general practitioner was managing him for diabetes.", + "The cystic lesion was observed over the course of three and a half years.", + "The first image showed a 5 cm cystic mass with a uniform high density.", + "The first image showed a CT value of 101 Hounsfield Units.", + "The second image showed the cystic lesion had grown to 8 cm.", + "The second image showed the internal density had decreased to 28 Hounsfield Units.", + "Eventually, the cyst diameter increased further to 10 cm.", + "Eventually, the CT value decreased slightly to 20 Hounsfield Units.", + "Retroperitoneal lymphangioma was listed as a differential diagnosis.", + "Dermoid cyst was listed as a differential diagnosis.", + "Mucinous cystadenoma of appendix was listed as a differential diagnosis.", + "It would be difficult to make an accurate diagnosis of the retroperitoneal lesion.", + "Malignant transformation could not be denied as a reason for the enlargement.", + "Surgical resection was planned rather than careful follow-up.", + "Laparoscopic surgery was performed under general anesthesia.", + "The operative procedure began with the insertion of a 1.2 cm umbilical port using Hasson’s technique.", + "Four additional ports were inserted under direct visualization.", + "The large cystic mass was identified in the retroperitoneal space below the right kidney.", + "The cystic mass was firmly adhered to the appendix and mesentery via the retroperitoneum.", + "The appendix was dissected with a linear stapler.", + "The appendix was resected en bloc with the cystic lesion.", + "Some feeding vessels from the right gonadal vessel were clipped and cut.", + "The lesion was not associated with the colonic wall.", + "The lesion was not associated with the ureter.", + "The lesion could be completely dissected without injury to the surrounding organs.", + "The lesion was placed in an entrapment endobag.", + "The lesion was removed from the abdomen via the umbilical port site.", + "The total operative time was 157 min.", + "The estimated blood loss was small.", + "The patient made an uneventful recovery.", + "The patient was discharged home on postoperative day 4.", + "The resected specimens consisted of a unilocular cystic tumor of 10 cm in maximum diameter.", + "The cystic tumor had a smooth inner surface.", + "The cystic lesion included a large amount of yellow, turbid serous fluid.", + "Hematoxylin and eosin staining demonstrated the smooth muscular layers in the cystic wall.", + "The smooth muscular layers were consistent with the muscularis mucosae, submucosa, and muscularis propria of the gastrointestinal tract.", + "There was no communication with the appendix.", + "Desmin staining confirmed the intestinal wall structure of the muscularis mucosae and the muscularis propria.", + "The lining epithelial cells were positive for Mucin 2.", + "The final pathological diagnosis was IEDC in the retroperitoneal space.", + "There was no histological evidence of malignancy." + ], + "summary": "The patient was a 60-year-old male who received abdominal CT to investigate the cause of increased serum CA19-9 levels. CT revealed a unilocular cystic mass located in the lower right retroperitoneum. The size increased from 5 to 10 cm in three and a half years and the CT value decreased from 101 Hounsfield Units (HU) to 20 HU. We performed laparoscopic surgical resection, because the possibility that the enlargement of the lesion represented malignant transformation could not be denied. The large cystic mass firmly adhered to the appendix and its mesentery via the retroperitoneum, the appendix was resected en bloc with the cystic lesion. Microscopically, it had no communication with the appendix, and had an intestinal wall structure of muscularis mucosae and muscularis propria. The final pathological diagnosis was IEDC in the retroperitoneal space. There was no histological evidence of malignancy.", + "summary_subclaims": [ + "The patient was a 60-year-old male.", + "The patient received abdominal CT to investigate the cause of increased serum CA19-9 levels.", + "CT revealed a unilocular cystic mass located in the lower right retroperitoneum.", + "The size increased from 5 to 10 cm in three and a half years.", + "The CT value decreased from 101 Hounsfield Units (HU) to 20 HU.", + "Laparoscopic surgical resection was performed.", + "The possibility that the enlargement of the lesion represented malignant transformation could not be denied.", + "The large cystic mass firmly adhered to the appendix and its mesentery via the retroperitoneum.", + "The appendix was resected en bloc with the cystic lesion.", + "Microscopically, it had no communication with the appendix.", + "It had an intestinal wall structure of muscularis mucosae and muscularis propria.", + "The final pathological diagnosis was IEDC in the retroperitoneal space.", + "There was no histological evidence of malignancy." + ] + }, + { + "id": "multiclinsum_test_1714_en.txt", + "fulltext": "This was a 30-year-old female who presented at the outpatient clinic with a three-month history of progressive low back pain and leg neuropathic pain. She reported paresthesia of both lower limbs predominantly on the right side reaching up to the inguinal regions. The paresthesia was more prominent at night, and it was refractory to medical therapy. She denied any weakness, bowel or bladder dysfunction, or upper limb affection. Her past history was unremarkable. She was born to non-consanguineous parents, and she had no family history of similar condition, related neurological diseases, or neoplasia. Her general physical examination was unremarkable. Her neurological examination revealed mild clasp-knife spasticity in both lower limbs (particularly on the right side), bilateral extensor plantar response, brisk knee and ankle reflexes, sensory level at L1 with involvement of the saddle-shaped area (for pin-prick sensations).\nThe patient underwent lumbosacral magnetic resonance imaging (MRI) of the spine with contrast, and it revealed a T1 isointense, T2 hyperintense (A) intradural extramedullary lesion at the conus medullaris at L1 level with strong homogenous enhancement on contrast adminstration.\nThe patient underwent surgical laminectomy at L1, and the tumor was completely removed successfully without any residual (B to G). Histopathological examination by the hematoxylin and eosin (H&E) and immunohistochemistry of the excised mass revealed clusters of epithelioid cells arranged in a Zellballen pattern and separated by prominent fibrovascular stroma. The cells were oval to polygonal with abundant granular cytoplasm and large nuclei. There were no mitotic figures or features of nuclear atypia. The histopathological features were suggestive of paraganglioma. The postoperative follow-up was uneventful. The patient recovered completely, and she is pain-free to date.", + "fulltext_subclaims": [ + "The patient was a 30-year-old female.", + "She presented with a three-month history of progressive low back pain.", + "She had leg neuropathic pain.", + "She reported paresthesia of both lower limbs predominantly on the right side.", + "The paresthesia reached up to the inguinal regions.", + "The paresthesia was more prominent at night.", + "The paresthesia was refractory to medical therapy.", + "She denied any weakness.", + "She denied bowel or bladder dysfunction.", + "She denied upper limb affection.", + "Her past history was unremarkable.", + "She was born to non-consanguineous parents.", + "She had no family history of similar condition.", + "Her general physical examination was unremarkable.", + "Her neurological examination revealed mild clasp-knife spasticity in both lower limbs.", + "The clasp-knife spasticity was particularly on the right side.", + "She had bilateral extensor plantar response.", + "She had brisk knee and ankle reflexes.", + "There was a sensory level at L1 with involvement of the saddle-shaped area for pin-prick sensations.", + "The patient underwent lumbosacral magnetic resonance imaging (MRI) of the spine with contrast.", + "The MRI revealed a T1 isointense lesion at the conus medullaris at L1 level.", + "The lesion was T2 hyperintense.", + "The lesion showed strong homogenous enhancement on contrast administration.", + "The patient underwent surgical laminectomy at L1.", + "The tumor was completely removed successfully without any residual.", + "Histopathological examination was performed using hematoxylin and eosin (H&E) and immunohistochemistry.", + "The excised mass revealed clusters of epithelioid cells arranged in a Zellballen pattern.", + "The cells were separated by prominent fibrovascular stroma.", + "The cells were oval to polygonal with abundant granular cytoplasm and large nuclei.", + "There were no mitotic figures.", + "There were no features of nuclear atypia.", + "The histopathological features were suggestive of paraganglioma.", + "The postoperative follow-up was uneventful.", + "The patient recovered completely.", + "The patient is pain-free to date." + ], + "summary": "In this article, we present a 30-year-old lady who presented with low back pain and radicular neuropathic pain at L1 dermatome which was intractable to medical surgery. Her magnetic resonance imaging (MRI) of the lumbosacral spine revealed a T1 isointense, T2 heterogeneously hyperintense intradural extramedullary lesion at the conus medullaris with strong homogenous enhancement on contrast administration. The lesion was surgically excised completely with L1 laminectomy, and the histopathological picture was suggestive of paraganglioma. The patient's complaints resolved fully postoperatively, and there was no evidence of recurrence on long-term follow-up.", + "summary_subclaims": [ + "The patient was a 30-year-old lady.", + "She presented with low back pain.", + "She had radicular neuropathic pain at L1 dermatome.", + "Her pain was intractable to medical surgery.", + "MRI of the lumbosacral spine showed a T1 isointense lesion.", + "The lesion was intradural extramedullary.", + "The lesion was at the conus medullaris.", + "The lesion was heterogeneously hyperintense on T2.", + "The lesion showed strong homogenous enhancement on contrast administration.", + "The lesion was surgically excised completely.", + "L1 laminectomy was performed.", + "The histopathological picture was suggestive of paraganglioma.", + "The patient's complaints resolved fully postoperatively.", + "There was no evidence of recurrence on long-term follow-up." + ] + }, + { + "id": "multiclinsum_test_2878_en.txt", + "fulltext": "A 48-year-old Japanese man presented with symptoms of right-sided facial asymmetry and right hand palsy that had lasted for 10 days. He had a past medical history of syphilis, gonorrhea, varicella, hepatitis B viral infection, and chronic use of tobacco (1–2 packs of cigarettes per day for 28 years). Laboratory examinations revealed positivity for human immunodeficiency virus (HIV) antigen/antibody, a CD4 positive lymphocyte count of 84 cells/μL, and an HIV-1 RNA viral load of 180,000 copies/mL. Contrast-enhanced magnetic resonance imaging of the head showed three mass lesions in the brain, and the specimen biopsy from these lesions revealed diffuse large B cell lymphoma. He was diagnosed with AIDS-associated primary brain malignant lymphoma. The patient was administered emtricitabine/tenofovir disoproxil combination therapy and raltegravir as the antiretroviral therapy. Atovaquone and azithromycin were also used for prophylaxis of pneumocystis pneumonia and nontuberculous mycobacterial infections.\nA PICC was implanted, and he received five courses of R-CHOP chemotherapy (, , , , and prednisone). Five days after the last R-CHOP chemotherapy course, he suddenly developed a fever with shivering chills. His white blood cell count was 4300/μL, and his neutrophil count was 4200/μL. The CD4-positive lymphocyte cell count was 228 cells/μL, and the HIV-1 RNA viral load was 20 copies/mL. We administered 2 g cefozopran hydrochloride, which is a fourth generation cephalosporin, and vancomycin on day 1 (every 12 h) and on day 3, respectively, and the PICC was removed. The patient’s condition improved and become afebrile within 48 h after the initiation of cefozopran hydrochloride. Cultures obtained from blood and revealed gram-positive rods, which were identified as T. pulmonis using 16S ribosomal RNA gene sequencing. The colony count of T. pulmonis grown from PICC culture was 103 colony-forming units. Thus, he was diagnosed with T. pulmonis bacteremia resulting from a PICC-related bloodstream infection. Because of the results of the susceptibility test , we continued cefozopran hydrochloride for 16 days. Follow up blood culture on 5 days after treatment was negative and clinical relapse was not observed. He remains in complete remission as of this report.", + "fulltext_subclaims": [ + "The patient is a 48-year-old Japanese man.", + "The patient had right-sided facial asymmetry and right hand palsy lasting for 10 days.", + "The patient had a past medical history of syphilis.", + "The patient had a past medical history of gonorrhea.", + "The patient had a past medical history of varicella.", + "The patient had a past medical history of hepatitis B viral infection.", + "The patient had chronic use of tobacco (1–2 packs of cigarettes per day for 28 years).", + "Laboratory examinations revealed positivity for human immunodeficiency virus (HIV) antigen/antibody.", + "The CD4 positive lymphocyte count was 84 cells/μL.", + "The HIV-1 RNA viral load was 180,000 copies/mL.", + "Contrast-enhanced magnetic resonance imaging of the head showed three mass lesions in the brain.", + "The specimen biopsy from the brain lesions revealed diffuse large B cell lymphoma.", + "The patient was diagnosed with AIDS-associated primary brain malignant lymphoma.", + "The patient was administered emtricitabine/tenofovir disoproxil combination therapy.", + "The patient was administered raltegravir as the antiretroviral therapy.", + "The patient received five courses of R-CHOP chemotherapy.", + "Five days after the last R-CHOP chemotherapy course, the patient developed a fever with shivering chills.", + "The white blood cell count was 4300/μL.", + "The neutrophil count was 4200/μL.", + "The CD4-positive lymphocyte cell count was 228 cells/μL.", + "The HIV-1 RNA viral load was 20 copies/mL.", + "Cefozopran hydrochloride was administered.", + "Vancomycin was administered on day 1 and on day 3.", + "The PICC was removed.", + "The patient became afebrile within 48 h after the initiation of cefozopran hydrochloride.", + "Blood cultures revealed gram-positive rods.", + "The gram-positive rods were identified as T. pulmonis using 16S ribosomal RNA gene sequencing.", + "The colony count of T. pulmonis grown from PICC culture was 103 colony-forming units.", + "The patient was diagnosed with T. pulmonis bacteremia resulting from a PICC-related bloodstream infection.", + "Cefozopran hydrochloride was continued for 16 days.", + "Follow up blood culture on 5 days after treatment was negative.", + "Clinical relapse was not observed.", + "The patient remains in complete remission as of this report." + ], + "summary": "We describe a case of a 48-year-old man with acquired immunodeficiency syndrome and diffuse large B cell lymphoma who received five courses of chemotherapy including rituximab , cyclophosphamide , doxorubicin hydrochloride , vincristine , and prednisone via a PICC. Five days after the last chemotherapy course, he presented with a high fever and shaking chills. His absolute neutrophil count was 4200/μL. Cultures obtained from blood and PICC culture revealed T. pulmonis. The colony count of T. pulmonis grown from PICC culture was 103 colony-forming units. Therefore, he was diagnosed with T. pulmonis bacteremia resulting from PICC-related bloodstream infection. The patient's condition improved and he became afebrile within 48 h after intravenous administration of cefozopran hydrochloride, which is a fourth generation cephalosporin.", + "summary_subclaims": [ + "The patient was a 48-year-old man.", + "The patient had acquired immunodeficiency syndrome.", + "The patient had diffuse large B cell lymphoma.", + "The patient received five courses of chemotherapy.", + "The chemotherapy included rituximab.", + "The chemotherapy included cyclophosphamide.", + "The chemotherapy included doxorubicin hydrochloride.", + "The chemotherapy included vincristine.", + "The chemotherapy included prednisone.", + "The chemotherapy was administered via a PICC.", + "Five days after the last chemotherapy course, the patient presented with a high fever.", + "Five days after the last chemotherapy course, the patient had shaking chills.", + "The patient's absolute neutrophil count was 4200/μL.", + "Blood cultures were obtained.", + "PICC culture was obtained.", + "Blood and PICC cultures revealed T. pulmonis.", + "The colony count of T. pulmonis grown from PICC culture was 103 colony-forming units.", + "The patient was diagnosed with T. pulmonis bacteremia.", + "The diagnosis was T. pulmonis bacteremia resulting from PICC-related bloodstream infection.", + "The patient received intravenous administration of cefozopran hydrochloride.", + "Cefozopran hydrochloride is a fourth generation cephalosporin.", + "The patient became afebrile within 48 hours after receiving cefozopran hydrochloride." + ] + }, + { + "id": "multiclinsum_test_134_en.txt", + "fulltext": "The patient was a 48-year-old female with a 20-month history of right-sided orofacial pain. Her main complaint was paroxysmal pain in her auditory canal, pinna, deep in the jaw, and adjacent retromastoid area on the right side. The pain was described as a burning sensation in an area located in the posterior external auditory canal wall and was elicited by chewing, touch, or contact with objects or warm water. It usually lasted for a few seconds to 1–2 min and would remit spontaneously and abruptly. The patient ranked it 10 on the numeric rating scale. She had no odynophagia and was treated with carbamazepine (maximum 1200 mg/day), which proved to be ineffective. Other medications (Sertraline, Amitriptyline, and Pregabalin) also failed to provide clinically significant pain relief. The patient's otoscopic examination was unremarkable bilaterally. There was no sensory loss, facial palsy, or other neurological signs.\nThe patient underwent preoperative MRI and MRI angiography, including 3D T2-weighted fast spin echo and 3D constructive interference in the steady-state (CISS) sequences. Images showed the right posterior cerebellar artery crossing the cerebello-pontine cistern [arrow in ] in close contact with the right VII and VIII nerves [arrow in ], near the internal auditory canal.\nA right-sided suboccipital retrosigmoid craniotomy was performed. The patient was put in a left lateral decubitus position, with the head well rotated and fixed in a Mayfield clamp. The dura was opened. Minimal retraction of the cerebellum was performed to achieve cerebrospinal fluid (CSF) drainage. In the cerebello-pontine angle, as shown in , the loop [arrow-head in ] of the PICA was visualized, as well as the close contact between the vascular structure and the VII-VIII nerves complex [* in ]. Additional exploration did not reveal other areas of neurovascular conflict at the roots of the trigeminal nerve or the lower cranial nerves. The artery's arachnoid attachment was dissected, the artery mobilized, and a small Teflon felt was placed to separate the artery from the nerve. Sectioning of the intermediate nerve or excision of the geniculate ganglion (GG) was not necessary.\nFollowing the decompression, the patient had an uneventful postoperative recovery and the pain resolved immediately with no additional neurological deficits, demonstrating that the compression was the only cause of pain. Postoperative CT scans were unremarkable. Medication was tapered off in the first few weeks after surgery. At 6-months’ follow-up, no further paroxysmal pain had occurred.", + "fulltext_subclaims": [ + "The patient was a 48-year-old female with a 20-month history of right-sided orofacial pain.", + "Her main complaint was paroxysmal pain in her auditory canal, pinna, deep in the jaw, and adjacent retromastoid area on the right side.", + "The pain was described as a burning sensation in an area located in the posterior external auditory canal wall.", + "The pain was elicited by chewing, touch, or contact with objects or warm water.", + "The pain usually lasted for a few seconds to 1–2 min and would remit spontaneously and abruptly.", + "The patient ranked the pain 10 on the numeric rating scale.", + "She had no odynophagia.", + "She was treated with carbamazepine (maximum 1200 mg/day), which proved to be ineffective.", + "Other medications (Sertraline, Amitriptyline, and Pregabalin) also failed to provide clinically significant pain relief.", + "The patient's otoscopic examination was unremarkable bilaterally.", + "There was no sensory loss, facial palsy, or other neurological signs.", + "The patient underwent preoperative MRI and MRI angiography, including 3D T2-weighted fast spin echo and 3D constructive interference in the steady-state (CISS) sequences.", + "Images showed the right posterior cerebellar artery crossing the cerebello-pontine cistern.", + "The right posterior cerebellar artery was in close contact with the right VII and VIII nerves, near the internal auditory canal.", + "A right-sided suboccipital retrosigmoid craniotomy was performed.", + "The patient was put in a left lateral decubitus position, with the head well rotated and fixed in a Mayfield clamp.", + "The dura was opened.", + "Minimal retraction of the cerebellum was performed to achieve cerebrospinal fluid (CSF) drainage.", + "In the cerebello-pontine angle, the loop of the PICA was visualized.", + "The close contact between the vascular structure and the VII-VIII nerves complex was observed.", + "Additional exploration did not reveal other areas of neurovascular conflict at the roots of the trigeminal nerve or the lower cranial nerves.", + "The artery's arachnoid attachment was dissected.", + "The artery was mobilized.", + "A small Teflon felt was placed to separate the artery from the nerve.", + "Sectioning of the intermediate nerve or excision of the geniculate ganglion was not necessary.", + "Following the decompression, the patient had an uneventful postoperative recovery.", + "The pain resolved immediately with no additional neurological deficits.", + "Postoperative CT scans were unremarkable.", + "Medication was tapered off in the first few weeks after surgery.", + "At 6-months’ follow-up, no further paroxysmal pain had occurred." + ], + "summary": "We present the case of a 48-year-old female with a 20-month history of intractable paroxysmal INN on the right side. The patient described feeling paroxysmal pain in her auditory canal, pinna, deep in the jaw, and adjacent retromastoid area on the right side. She described the pain as being like a burning sensation. Magnetic resonance imaging showed the right posterior cerebellar artery crossing the cerebellopontine cistern in close contact with the right VII and VIII nerves. Surgical exploration via retromastoid craniotomy revealed vascular compression of the intermediate nerve by the posterior cerebellar artery. We therefore performed microvascular nerve decompression to relieve pain, and the patient remained pain-free at the 6-month follow-up visit.", + "summary_subclaims": [ + "The patient is a 48-year-old female.", + "She has a 20-month history of intractable paroxysmal INN on the right side.", + "The patient described feeling paroxysmal pain in her auditory canal.", + "The patient described feeling paroxysmal pain in her pinna.", + "The patient described feeling paroxysmal pain deep in the jaw.", + "The patient described feeling paroxysmal pain in the adjacent retromastoid area on the right side.", + "The pain was described as a burning sensation.", + "Magnetic resonance imaging showed the right posterior cerebellar artery crossing the cerebellopontine cistern.", + "The right posterior cerebellar artery was in close contact with the right VII and VIII nerves.", + "Surgical exploration via retromastoid craniotomy revealed vascular compression of the intermediate nerve by the posterior cerebellar artery.", + "Microvascular nerve decompression was performed to relieve pain.", + "The patient remained pain-free at the 6-month follow-up visit." + ] + }, + { + "id": "multiclinsum_test_1296_en.txt", + "fulltext": "A 19-year-old Caucasian man was admitted to our emergency department with a critical ischemia of his right ring finger due to a crushing injury. His finger had been caught between a car and a car-jack while he was working as a mechanic. The first physical examination of the ring finger revealed an open wound of 3 cm on the dorsal side of the middle phalanx. Edges of the wound reached the ulnar and radial digital neurovascular bundle. The patient reported decreased sensibility of the end phalanx including painful range of motion (ROM) but without loss of function of all tendons. We found a restricted finger blood flow detected by nail bed compression in comparison with the uninjured fingers. An X-ray showed an undislocated transverse fracture of the middle phalanx . The patient was immediately transferred to the operating room (OR) where the wound was examined. Severe damage of the surrounding soft tissue was seen. Microscopic examination revealed no defect of the crushed vessels, the radial digital nerve was intact, but an epineural lesion was apparent for the ulnar digital nerve. A minimal osteosynthesis with two Kirschner-wires (K-wires) was performed. X-ray imaging showed an anatomical retention and fixation of the fracture . The dorsal wound of the ring finger was cut out and sutured. The patient was discharged from the hospital on the fourth day without any sign of wound healing disturbance. The ring finger was immobilized with a finger splint including the proximal interphalangeal joint (PIP) and distal interphalangeal joint (DIP).\nThe patient was seen five months after initial treatment in our Out-Patient Clinic and reported painful moving of the right ring finger. The examination showed an instability of the middle phalanx with a passive lateral movement. Twenty degrees ulnar deviation of the ring finger with decreased ROM of the PIP joint (E/F 0-0-60˚) was apparent. In addition, the ring finger tended to cross over and overlap the adjacent finger when making a fist. The patient reported that ulna deviation of the ring finger started when K-wires had been removed by an office-based orthopedic surgeon two months after the initial surgery.\nSince that time the finger was fixed again with a splint. He also complained about tingling, coolness and numbness of the injured finger. Since the X-ray showed a nonunion we started treatment with a LIPUS device (Fa. Melmak GmbH, Munich, Germany) three times daily for 20 minutes including the following parameter configuration:\nAverage intensity I = 30 mW/cm² (SATA), ultrasound frequency F = 1.5 MHz, signal impulse duration 200 microseconds, repetition rate 1 kHz, effective radiating area 3.88 cm2, temporal average power 117 mW.\nThe ring finger was immobilized with a fitted personalized thermoplastic splint for six weeks. Six weeks after LIPUS treatment the patient reported to be without pain when moving his ring finger and clinical examination revealed a slight persistent ulna deviation of five degrees. The clinical examination showed a stable middle phalanx compared to the result six weeks previously. After four weeks of physiotherapy the ROM of the PIP joint was E/F 0-0-85° and the fist closure was full , except for the pre-existent limited ROM of the DIP-Joint (E/F 0-0-15˚). An X-ray confirmed fracture healing and calcification of the soft callus was clearly evident .", + "fulltext_subclaims": [ + "A 19-year-old Caucasian man was admitted to our emergency department with a critical ischemia of his right ring finger due to a crushing injury.", + "The first physical examination of the ring finger revealed an open wound of 3 cm on the dorsal side of the middle phalanx.", + "The patient reported decreased sensibility of the end phalanx including painful range of motion.", + "An X-ray showed an undislocated transverse fracture of the middle phalanx.", + "A minimal osteosynthesis with two Kirschner-wires (K-wires) was performed.", + "X-ray imaging showed an anatomical retention and fixation of the fracture.", + "The patient was discharged from the hospital on the fourth day without any sign of wound healing disturbance.", + "The patient was seen five months after initial treatment in our Out-Patient Clinic and reported painful moving of the right ring finger.", + "The examination showed an instability of the middle phalanx with a passive lateral movement.", + "Twenty degrees ulnar deviation of the ring finger with decreased ROM of the PIP joint (E/F 0-0-60˚) was apparent.", + "The patient reported that ulna deviation of the ring finger started when K-wires had been removed by an office-based orthopedic surgeon two months after the initial surgery.", + "Since that time the finger was fixed again with a splint.", + "The patient complained about tingling, coolness and numbness of the injured finger.", + "Since the X-ray showed a nonunion we started treatment with a LIPUS device.", + "The ring finger was immobilized with a fitted personalized thermoplastic splint for six weeks.", + "Six weeks after LIPUS treatment the patient reported to be without pain when moving his ring finger.", + "Clinical examination revealed a slight persistent ulna deviation of five degrees.", + "After four weeks of physiotherapy the ROM of the PIP joint was E/F 0-0-85°.", + "An X-ray confirmed fracture healing and calcification of the soft callus was clearly evident." + ], + "summary": "We report a case in which we successfully used LIPUS in a 19-year-old Caucasian man with a nonunion of his ring finger after injury and first treatment with K-wire osteosynthesis.", + "summary_subclaims": [ + "We report a case in which we successfully used LIPUS in a 19-year-old Caucasian man with a nonunion of his ring finger after injury and first treatment with K-wire osteosynthesis." + ] + }, + { + "id": "multiclinsum_test_818_en.txt", + "fulltext": "A 76-year-old man presented with a 12-month history of low back pain radiating down his right leg, without sensory dysfunction or motor weakness. Preoperative pain intensity was 8 on a 10-point scale and unresponsive to medication (i.e., continuous oral NSAIDs and 6 weeks of opioids). Preoperative MRI showed a paramedian, down-migrated, L3-L4 disc herniation (, B). Given the concordance between clinical symptoms and MRI findings, a right L3-L4 FETD was planned. From a prone position (, A), the patient underwent the procedure under monitored and local anesthesia (local infiltration with a 50/50 mixture of lidocaine 2% and physiological solution). Preoperatively midazolam 2 mg was intravenously administered for anxiety control. Propofol was administrated by continuous target-controlled infusion to achieve conscious sedation with spontaneous ventilation .\nThe Joimax TESSYS® (Joimax® GmbH, Karlsruhe, Germany) transforaminal endoscopic surgical system was used. We established the paramedian skin entry point, under fluoroscopic guidance, at approximately 10−11 cm lateral to the L4 spinous process. Using intermittent fluoroscopic guidance, alternating between lateral and anterior-posterior views, an 18-gauge needle was advanced until reaching the lateral border of the right L4 peduncle (,1). Then it was replaced by a soft Kirshner wire that served as a guide for introducing sequential dilators. The smallest dilatator (green guiding rod, outer diameter: 1.8 mm) was hammered inside the right L4 pedicle (,2). The trajectory was forced towards the medial wall of the pedicle to access the intracanal space After radiographic confirmation of the trajectory, the hole in the pedicle was increased with subsequential dilatators and reamers (outer diameters: from 3 to 7 mm). The instrument position was kept under radiographic control while continuously switching from lateral to AP views (,3). The reamers were used to cross the pedicle and penetrate the full width of the bone. The breaking of the medial pedicle wall, and thus the access to the intracanal space, was confirmed by simultaneously feeling the loss of resistance by hand and real-time fluoroscopic confirmation.\nWe then inserted the endoscope working cannula (8.0 mm in outer diameter) and the camera (,4). The herniated fragment was clearly visible (, A). We mobilized the disc fragment with the probe and the root retractor and then removed it with small forceps. The decompression was considered successful when we saw the nerve root pulsating freely in the epidural space (, B), after having checked the intraspinal space for additional fragments (, C). We closed with a resorbable suture.\nLate postoperative MRI showed satisfactory decompression (, C) and no sign of additional instability or fractures. Patient radiculopathy entirely resolved after the surgery – postoperative pain was negligible after the first 6 h and 24 h and at the 8-month follow-up.", + "fulltext_subclaims": [ + "The patient was a 76-year-old man.", + "He had a 12-month history of low back pain radiating down his right leg.", + "There was no sensory dysfunction.", + "There was no motor weakness.", + "Preoperative pain intensity was 8 on a 10-point scale.", + "The pain was unresponsive to medication.", + "Preoperative MRI showed a paramedian, down-migrated, L3-L4 disc herniation.", + "A right L3-L4 FETD was planned.", + "The procedure was performed under monitored and local anesthesia.", + "Local infiltration with a 50/50 mixture of lidocaine 2% and physiological solution was used.", + "Preoperatively midazolam 2 mg was intravenously administered.", + "Propofol was administered by continuous target-controlled infusion.", + "The Joimax TESSYS® transforaminal endoscopic surgical system was used.", + "The paramedian skin entry point was established at approximately 10−11 cm lateral to the L4 spinous process.", + "An 18-gauge needle was advanced until reaching the lateral border of the right L4 peduncle.", + "The smallest dilatator (green guiding rod, outer diameter: 1.8 mm) was hammered inside the right L4 pedicle.", + "The trajectory was forced towards the medial wall of the pedicle.", + "The hole in the pedicle was increased with sequential dilators and reamers.", + "The instrument position was kept under radiographic control.", + "The breaking of the medial pedicle wall was confirmed by simultaneously feeling the loss of resistance by hand and real-time fluoroscopic confirmation.", + "The endoscope working cannula (8.0 mm in outer diameter) was inserted.", + "The herniated fragment was clearly visible.", + "The decompression was considered successful when the nerve root was seen pulsating freely in the epidural space.", + "Late postoperative MRI showed satisfactory decompression.", + "There was no sign of additional instability or fractures.", + "Patient radiculopathy entirely resolved after the surgery.", + "Postoperative pain was negligible after the first 6 h and 24 h.", + "Postoperative pain was negligible at the 8-month follow-up." + ], + "summary": "We describe our experience in dealing with a right paramedian down-migrated L3-L4 disc herniation. The patient underwent full endoscopic transpedicular endoscopic discectomy (FETD), by reaming the right L4 peduncle for intracanal access and fragment retrieval. We also reviewed the recent literature to summarize the advantages of transpedicular approaches, along with current indications and contraindications for this procedure.", + "summary_subclaims": [ + "The patient had a right paramedian down-migrated L3-L4 disc herniation.", + "The patient underwent full endoscopic transpedicular endoscopic discectomy (FETD).", + "The right L4 peduncle was reamed for intracanal access.", + "Fragment retrieval was performed.", + "The recent literature was reviewed.", + "The advantages of transpedicular approaches were summarized.", + "Current indications and contraindications for this procedure were summarized." + ] + }, + { + "id": "multiclinsum_test_3226_en.txt", + "fulltext": "A 19-year-old woman (Gravida2, Para1) arrived at our hospital’s delivery and labor unit with significant vaginal bleeding and uterine contractions. There was no documented medical history for the patient. When being examined, the patient appeared healthy. The patient’s temperature was 35.4°C, oxygen saturation was 98%, her heart rate was 92 beats per minute, her blood pressure was 100/60 mm Hg, and her respiratory rate was 16 beats per minute. Trans abdominal ultrasound revealed fetus heart activity in a fetus at 24 weeks gestation; however, a large, heterogeneous, complex cystic mass was seen on the fundus, which was identified as an abnormal placenta with strong suspicion of molar tissue.\n\nA pelvic examination was performed and seen a 4-cm cervical dilation. On admission, the hemoglobin level was 9 mg/dL, and another laboratory test was all normal. She delivered a alive female fetus within 4 hours after admission. The placenta came out with the membrane and a lot of grape-like cystic within 20 minutes after delivery.\n\nThe mother’s vital signs were completely normal and stable.\n\nThe newborn weigh was 800 grams. Apgar scores were 4. The baby was referred to neonatal intensive care, but she died within 5 hours after delivery.\n\nThe histopathology examination of the placenta was diagnosed as a partial mole. The patient was follow-up weekly for 2 months, and laboratory testing showed a b-HCG level of 0 mIU/mL after those time.", + "fulltext_subclaims": [ + "The patient is a 19-year-old woman.", + "The patient is Gravida2, Para1.", + "The patient arrived at the hospital’s delivery and labor unit with significant vaginal bleeding.", + "The patient had uterine contractions.", + "There was no documented medical history for the patient.", + "The patient appeared healthy during examination.", + "The patient’s temperature was 35.4°C.", + "The patient’s oxygen saturation was 98%.", + "The patient’s heart rate was 92 beats per minute.", + "The patient’s blood pressure was 100/60 mm Hg.", + "The patient’s respiratory rate was 16 beats per minute.", + "Trans abdominal ultrasound revealed fetal heart activity.", + "The fetus was at 24 weeks gestation.", + "A large, heterogeneous, complex cystic mass was seen on the fundus.", + "The mass was identified as an abnormal placenta.", + "There was strong suspicion of molar tissue.", + "A pelvic examination showed 4-cm cervical dilation.", + "The hemoglobin level on admission was 9 mg/dL.", + "Other laboratory tests were all normal.", + "The patient delivered a live female fetus within 4 hours after admission.", + "The placenta came out with the membrane.", + "The placenta contained grape-like cystic structures.", + "The placenta was expelled within 20 minutes after delivery.", + "The mother’s vital signs were completely normal and stable.", + "The newborn weighed 800 grams.", + "The Apgar score was 4.", + "The baby was referred to neonatal intensive care.", + "The baby died within 5 hours after delivery.", + "The histopathology examination of the placenta was diagnosed as a partial mole.", + "The patient was followed up weekly for 2 months.", + "Laboratory testing showed a b-HCG level of 0 mIU/mL after 2 months." + ], + "summary": "n this case study, we present a 19-year-old woman who presented with acute vaginal bleeding and pelvic discomfort. Transabdominal ultrasound revealed fetal heart rate and identified the fetus at 24 weeks gestation. A large heterogeneous and complex cystic mass was found in the fundus, which was diagnosed as an abnormal placenta with a strong suspicion of molar pregnancy. The cervix was dilated by 4 cm at the time of hospital admission and four hours later, she gave birth to a healthy female fetus. The placenta emerged along with the membrane and abundant grape-like cystic tissue.", + "summary_subclaims": [ + "The patient was a 19-year-old woman.", + "She presented with acute vaginal bleeding and pelvic discomfort.", + "Transabdominal ultrasound revealed fetal heart rate.", + "The fetus was identified at 24 weeks gestation.", + "A large heterogeneous and complex cystic mass was found in the fundus.", + "The mass was diagnosed as an abnormal placenta with a strong suspicion of molar pregnancy.", + "The cervix was dilated by 4 cm at the time of hospital admission.", + "Four hours after admission, she gave birth to a healthy female fetus.", + "The placenta emerged along with the membrane and abundant grape-like cystic tissue." + ] + }, + { + "id": "multiclinsum_test_1542_en.txt", + "fulltext": "A 58-year-old woman from Grenada presented with a chief complaint of nausea, vomiting, and jaundice after her primary care physician (PCP) discovered elevated LFTs on routine labs.\nThe patient had a 10-day history of fatigue, nausea, and intermittent non-bilious, non-bloody emesis. Four to five days before admission, she noticed that her eyes began to turn yellow, prompting her to visit her PCP. These symptoms were also associated with decreased appetite, weight loss of 10 lbs, and dark urine. She stated that she did not take her statin medication regularly, but she reported drinking a “green juice” for the past 3 d before admission. It consisted of watercress, garlic, and ginger. The patient denied abdominal pain, diarrhea, constipation, other changes in diet, or other use of supplements.\nThe patient’s past medical history was significant for chronic hypertension, non-insulin-dependent diabetes mellitus, and hyperlipidemia. There was no history of excessive alcohol use.\nThe patient denied any family history of liver disease or autoimmune disorders.\nOn admission, the patient was hypertensive (blood pressure 168/98 mmHg), tachycardic (heart rate 77 beats per min), and afebrile (37.1 C F). She was alert and oriented. No asterixis was noted in her upper extremities. She had mild bilateral scleral icterus. An abdominal exam revealed an overweight, non-distended, non-tender abdomen with no masses, no hepatomegaly, no flank tenderness, and no fluid wave.\nThe laboratory work-up showed: Serum alanine aminotransferase (ALT) 2500 U/L (reference range 10-49 U/L), serum aspartate aminotransferase (AST) 3159 U/L (reference range 8-34 U/L), alkaline phosphatase 714 U/L (reference range 46-116 U/L), serum lipase 61 U/L (reference range 12-53 U/L), total bilirubin 6.4 mg/dL (reference range 0.3-1.2 mg/dL), direct bilirubin 4.4 mg/dL (reference range 0.1-0.3 mg/dL), prothrombin time 12.7 s, and INR 1.07. Table portrays a trend from admission to discharge of pertinent values. Serological markers for hepatotropic viruses such as A, B, C, and E were all negative. She had no clinical signs of infection. Further infective work-up revealed negative serology for cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1 & 2, and human immunodeficiency virus. All tested autoantibodies, including antinuclear antibody (ANA), smooth muscle antibody, anti-mitochondrial antibody, liver soluble antibody, and anti-liver kidney microsome 1 antibody, were negative . The patient was tested for Wilson’s disease, for which her ceruloplasmin levels came back as slightly elevated at 62 mg/dL. We attributed this to her current inflammatory state.\nAn abdominal ultrasound with Doppler showed no significant parenchymal abnormalities with normal arterial and venous Doppler of the liver and spleen. The gallbladder was contracted with no definite evidence of cholecystitis . A follow-up magnetic resonance cholangiopancreatography (MRCP) with and without contrast was then conducted to rule out biliary causes of acute hepatitis . The MRCP showed a biliary system with no filling defects, stones, or ductal dilation. All other organs were within normal limits.\nThe patient underwent a liver biopsy, which showed moderate to severe active hepatitis with focal confluent necrosis, consisting mostly of lymphocytes with few eosinophils, plasma cells, and neutrophils with scattered acidophil bodies. Her biopsy was negative for cholestasis, granulomas, or malignancy . Differentials from the pathology report include drug/toxin/herbal/supplement-induced injury and infection (including viral hepatitis E), and less likely immune-mediated injury given negative autoimmune workup (negative ANA, anti-smooth muscle antibody, anti-mitochondrial antibody, anti-liver kidney microsome-1 antibody, and anti-soluble liver antigen antibody).", + "fulltext_subclaims": [ + "The patient is a 58-year-old woman from Grenada.", + "She presented with nausea, vomiting, and jaundice.", + "Her primary care physician discovered elevated LFTs on routine labs.", + "She had a 10-day history of fatigue, nausea, and intermittent non-bilious, non-bloody emesis.", + "Four to five days before admission, she noticed that her eyes began to turn yellow.", + "She had decreased appetite, weight loss of 10 lbs, and dark urine.", + "She did not take her statin medication regularly.", + "She reported drinking a green juice for the past 3 d before admission.", + "The green juice consisted of watercress, garlic, and ginger.", + "She denied abdominal pain, diarrhea, constipation, other changes in diet, or other use of supplements.", + "The patient’s past medical history was significant for chronic hypertension.", + "The patient’s past medical history was significant for non-insulin-dependent diabetes mellitus.", + "The patient’s past medical history was significant for hyperlipidemia.", + "There was no history of excessive alcohol use.", + "She denied any family history of liver disease or autoimmune disorders.", + "On admission, the patient was hypertensive (blood pressure 168/98 mmHg).", + "On admission, the patient was tachycardic (heart rate 77 beats per min).", + "On admission, the patient was afebrile (37.1 C F).", + "She had mild bilateral scleral icterus.", + "An abdominal exam revealed an overweight, non-distended, non-tender abdomen with no masses.", + "Serum alanine aminotransferase (ALT) was 2500 U/L.", + "Serum aspartate aminotransferase (AST) was 3159 U/L.", + "Alkaline phosphatase was 714 U/L.", + "Total bilirubin was 6.4 mg/dL.", + "Direct bilirubin was 4.4 mg/dL.", + "Serological markers for hepatotropic viruses such as A, B, C, and E were all negative.", + "Further infective work-up revealed negative serology for cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1 & 2, and human immunodeficiency virus.", + "All tested autoantibodies, including antinuclear antibody (ANA), smooth muscle antibody, anti-mitochondrial antibody, liver soluble antibody, and anti-liver kidney microsome 1 antibody, were negative.", + "Ceruloplasmin levels were slightly elevated at 62 mg/dL.", + "An abdominal ultrasound with Doppler showed no significant parenchymal abnormalities.", + "The gallbladder was contracted with no definite evidence of cholecystitis.", + "A follow-up magnetic resonance cholangiopancreatography (MRCP) with and without contrast was conducted.", + "The MRCP showed a biliary system with no filling defects, stones, or ductal dilation.", + "The liver biopsy showed moderate to severe active hepatitis with focal confluent necrosis.", + "The biopsy was negative for cholestasis, granulomas, or malignancy.", + "Differentials from the pathology report include drug/toxin/herbal/supplement-induced injury.", + "Differentials from the pathology report include infection (including viral hepatitis E).", + "Differentials from the pathology report include immune-mediated injury." + ], + "summary": "We present the case of a 58-year-old woman who presented to the emergency room for elevated liver function tests (LFTs). Her symptoms started 10 d prior to admission and included nausea, vomiting, jaundice, decreased appetite, weight loss of 10 lbs, and dark urine. She denied drinking alcohol or taking any hepatotoxic agents, including acetaminophen, statins, vitamins, or supplements. She was admitted to the hospital, and an etiologic work-up was carried out. Her initial bloodwork revealed elevated liver enzymes (alanine aminotransferase 2500 U/L, aspartate aminotransferase 3159 U/L, and alkaline phosphatase 714 U/L) and elevated total bilirubin of 6.4 mg/dL. She tested negative for common infectious etiologies such as hepatotropic viruses A, B, C, and E. Further infective work-up revealed negative serology for cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1 & 2, and human immunodeficiency virus. Her autoantibody test results were negative, including anti-smooth muscle antibody, anti-mitochondrial antibody, and anti-liver kidney microsome 1 antibody. Magnetic resonance cholangiopancreatography ruled out biliary causes of elevated LFTs, and her core liver biopsy proved inconclusive. Over the course of her hospital stay, the patient's LFTs improved with supportive care and without steroids.", + "summary_subclaims": [ + "The patient is a 58-year-old woman.", + "She presented to the emergency room for elevated liver function tests.", + "Her symptoms started 10 d prior to admission.", + "She had nausea, vomiting, jaundice, decreased appetite, weight loss of 10 lbs, and dark urine.", + "She denied drinking alcohol.", + "She denied taking any hepatotoxic agents, including acetaminophen, statins, vitamins, or supplements.", + "Her initial bloodwork revealed elevated liver enzymes (alanine aminotransferase 2500 U/L, aspartate aminotransferase 3159 U/L, and alkaline phosphatase 714 U/L).", + "Her total bilirubin was 6.4 mg/dL.", + "She tested negative for hepatotropic viruses A, B, C, and E.", + "Further infective work-up revealed negative serology for cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1 & 2, and human immunodeficiency virus.", + "Her autoantibody test results were negative, including anti-smooth muscle antibody, anti-mitochondrial antibody, and anti-liver kidney microsome 1 antibody.", + "Magnetic resonance cholangiopancreatography ruled out biliary causes of elevated LFTs.", + "Her core liver biopsy proved inconclusive.", + "Over the course of her hospital stay, the patient's LFTs improved with supportive care and without steroids." + ] + }, + { + "id": "multiclinsum_test_2460_en.txt", + "fulltext": "A 63-year-old man complaining of discomfort in the upper right abdomen was referred to our hospital because of a liver tumor diagnosed by another hospital.\nPreviously, he had undergone an appendectomy, and had a history of untreated chronic hepatitis C and a daily habit of drinking. His physical examination revealed no notable abnormalities. The abnormal values in his blood test findings were as follows: aspartate transaminase, 71 IU/l; alanine transaminase, 108 IU/l; alpha-fetoprotein, 5626.0 ng/ml; and protein induced by vitamin K absence or antagonist II, 642 mAU/ml. Other blood counts, biochemical laboratory findings and coagulation factors were within the normal ranges. The retention rate of indocyanine green at 15 min was 10%.\nContrast-enhanced computed tomography (CT) showed a 40-mm tumor in segment 8 (S8) of the liver, which was enhanced in the early phase and washed out in the delayed phase, suggesting hepatocellular carcinoma (HCC) . His portal vein was lying ventral to the pancreas and dorsal to the duodenum (hence called PPPV), and ventral to the common bile duct . In the hepatic hilus, the portal vein was dilated, forming an inverted L-shape, and was branching while winding with an irregular caliber . In addition, there were some porto-portal communications . No anomalies were detected in the common bile duct, gallbladder, hepatic artery, and there were no esophageal or gastric varices, thrombus, and portosystemic collaterals.\nBecause of this anomalous configuration, the Glissonean approach at the hepatic hilum or anatomical resection was judged to be dangerous; therefore, we performed partial resection of S8. During the operation, the liver had a chronic hepatitis pattern and ascites was not observed. No morphological malformations were detected in the liver or in other organs. Intraoperative ultrasonography showed worm-like meandering of the intrahepatic portal veins, but no occlusion findings due to a thrombus . We performed liver resection with a margin of 2 cm from the tumor without the Pringle maneuver . The operative time was 431 min, and the amount of blood loss was 785 ml. The final pathological diagnosis was moderately differentiated hepatocellular carcinoma with an UICC classification of pT2N0M0, Stage II. The fibrosis stage and inflammatory grade of the resected liver were both F3A2 according to the New Inuyama classification. The postoperative course was uneventful, and the patient was discharged 14 days after the surgery.", + "fulltext_subclaims": [ + "A 63-year-old man complaining of discomfort in the upper right abdomen was referred to our hospital because of a liver tumor diagnosed by another hospital.", + "He had a history of untreated chronic hepatitis C.", + "The abnormal values in his blood test findings were as follows: aspartate transaminase, 71 IU/l; alanine transaminase, 108 IU/l; alpha-fetoprotein, 5626.0 ng/ml; and protein induced by vitamin K absence or antagonist II, 642 mAU/ml.", + "Contrast-enhanced computed tomography showed a 40-mm tumor in segment 8 of the liver, which was enhanced in the early phase and washed out in the delayed phase, suggesting hepatocellular carcinoma.", + "The portal vein was lying ventral to the pancreas and dorsal to the duodenum.", + "In the hepatic hilus, the portal vein was dilated, forming an inverted L-shape, and was branching while winding with an irregular caliber.", + "There were some porto-portal communications.", + "Because of this anomalous configuration, the Glissonean approach at the hepatic hilum or anatomical resection was judged to be dangerous.", + "We performed partial resection of segment 8.", + "Intraoperative ultrasonography showed worm-like meandering of the intrahepatic portal veins, but no occlusion findings due to a thrombus.", + "We performed liver resection with a margin of 2 cm from the tumor without the Pringle maneuver.", + "The final pathological diagnosis was moderately differentiated hepatocellular carcinoma with an UICC classification of pT2N0M0, Stage II." + ], + "summary": "A 63-year-old man was admitted to our hospital for treatment of a liver tumor. After examination, he was diagnosed with hepatocellular carcinoma with a diameter of 40 mm in segment 8. Contrast-enhanced computed tomography scan showed a portal vein passing between the duodenum and pancreas, hence called PPPV. At the hepatic hilus, the portal vein branched off in a complicated course with some porto-portal communications. We determined that anatomical resection with manipulation of the hepatic hilum in this case resulted in major vascular injury. Therefore, we performed partial liver resection, and the patient was discharged uneventfully on postoperative day 14.", + "summary_subclaims": [ + "The patient was a 63-year-old man.", + "He was admitted to our hospital for treatment of a liver tumor.", + "After examination, he was diagnosed with hepatocellular carcinoma.", + "The tumor had a diameter of 40 mm.", + "The tumor was located in segment 8.", + "Contrast-enhanced computed tomography scan showed a portal vein passing between the duodenum and pancreas.", + "The portal vein was called PPPV.", + "At the hepatic hilus, the portal vein branched off in a complicated course.", + "There were some porto-portal communications.", + "We determined that anatomical resection with manipulation of the hepatic hilum in this case resulted in major vascular injury.", + "We performed partial liver resection.", + "The patient was discharged uneventfully on postoperative day 14." + ] + }, + { + "id": "multiclinsum_test_3181_en.txt", + "fulltext": "A 34-year-old female patient in the second trimester of pregnancy presented to the emergency department with complaints of moderate intensity pain in the lower abdomen, predominantly on the right side, which had been present for 3 weeks and had worsened markedly in the last 2 days. The patient did not have any other symptoms apart from the referred pain, such as fever, loss of appetite, nausea or vomiting. Given the diagnosis of abdominal pain predominantly in the right iliac fossa, laboratory tests were requested to assess inflammatory and infectious activity, and ultrasound (USG) of the total abdomen was performed in the emergency radiology department.\n\nThe USG confirmed the pregnancy without obvious changes related to the uterus, placenta and foetus. The evaluation directed to the right iliac fossa did not characterise signs suggestive of acute appendicitis, which, in this context, would be hyperecogenicity and densification of the pericecal and/or periapendicular fat, locoregional lymphadenomegaly of reactive aspect with cortical thickening and, sometimes, increased flow to colour Doppler mapping and presence of laminar free liquid or in the form of locoregional collection. The cecal appendix was thickened in the body portion, reaching 9.2 mm in maximum transverse diameter (considered normal up to about 6.0 mm) and with segmental increase in calibre in that region, without other characteristics of inflammatory nature. In the thickened region, the lumen of the appendix was collapsed, and the wall of the organ presented increased echogenicity, homogeneously, and with echotexture similar to that of fat. The appendicular compressibility was slightly reduced. In the region of the apical appendix, the outer diameter was within the normal limits (4.5 mm). Colour Doppler mapping did not show increased flow. There were also no signs of hyperecogenicity of the periapendicular fat.\n\nLaboratory tests did not show any changes (leukocytes and C-reactive protein within normal limits). The findings of the ultrasound did not suggest an acute inflammatory process, but rather benign changes of a probable infiltrative fatty nature. An MRI was requested to complement the diagnosis.\n\nThe MRI confirmed the findings described in the USG, with focal parietal thickening of the appendix without inflammatory signs. Diffuse hypersignal of the appendix was observed in the in-phase sequence, with loss of signal in the out-phase sequence, indicating the presence of a significant amount of fat in the intracellular compartment, characteristic of lipomatosis. There was no appreciable enhancement in the appendix in the MRI examination. In view of the clinical and laboratory findings and the characteristics of the USG and the MRI, the diagnosis of lipomatosis could be confirmed. The patient was discharged with analgesia, without return of the symptoms.\n", + "fulltext_subclaims": [ + "The patient is a 34-year-old female in the second trimester of pregnancy.", + "The patient presented with moderate intensity pain in the lower abdomen, predominantly on the right side.", + "The pain had been present for 3 weeks and had worsened markedly in the last 2 days.", + "The patient did not have fever, loss of appetite, nausea, or vomiting.", + "The diagnosis was abdominal pain predominantly in the right iliac fossa.", + "Laboratory tests were requested to assess inflammatory and infectious activity.", + "An ultrasound of the total abdomen was performed.", + "The ultrasound confirmed the pregnancy without obvious changes related to the uterus, placenta, and foetus.", + "The ultrasound did not characterise signs suggestive of acute appendicitis.", + "The cecal appendix was thickened in the body portion, reaching 9.2 mm in maximum transverse diameter.", + "The lumen of the thickened appendix was collapsed.", + "The wall of the appendix presented increased echogenicity, homogeneously, and with echotexture similar to that of fat.", + "The appendicular compressibility was slightly reduced.", + "The outer diameter of the apical appendix was within normal limits (4.5 mm).", + "Color Doppler mapping did not show increased flow.", + "There were no signs of hyperecogenicity of the periapendicular fat.", + "Laboratory tests did not show any changes (leukocytes and C-reactive protein within normal limits).", + "The ultrasound findings did not suggest an acute inflammatory process.", + "An MRI was requested to complement the diagnosis.", + "The MRI confirmed the findings described in the ultrasound.", + "The MRI showed focal parietal thickening of the appendix without inflammatory signs.", + "Diffuse hypersignal of the appendix was observed in the in-phase sequence with loss of signal in the out-phase sequence.", + "The MRI indicated the presence of a significant amount of fat in the intracellular compartment, characteristic of lipomatosis.", + "There was no appreciable enhancement in the appendix in the MRI examination.", + "The diagnosis of lipomatosis could be confirmed.", + "The patient was discharged with analgesia.", + "The patient did not have a return of the symptoms." + ], + "summary": "34-year-old pregnant female patient presented to the emergency department with complaints of right iliac pain that had been worsening for the past 2 days with suspicion of acute appendicitis. Laboratory tests were requested, which were within the normal limits for infectious and inflammatory aspects. Imaging tests were also requested, with ultrasound being the method of choice, which revealed an ongoing pregnancy with no changes and a thickness of the appendix wall with no inflammatory signs. Still with suspicion of acute appendicitis, magnetic resonance imaging was performed, confirming the hypothesis of lipomatosis of the cecal appendix.\n", + "summary_subclaims": [ + "The patient is a 34-year-old pregnant female.", + "She presented to the emergency department with right iliac pain.", + "The pain had been worsening for the past 2 days.", + "There was suspicion of acute appendicitis.", + "Laboratory tests were requested.", + "The laboratory tests were within the normal limits for infectious and inflammatory aspects.", + "Imaging tests were requested.", + "Ultrasound was the method of choice.", + "Ultrasound revealed an ongoing pregnancy with no changes.", + "Ultrasound showed a thickness of the appendix wall with no inflammatory signs.", + "Magnetic resonance imaging was performed.", + "Magnetic resonance imaging confirmed the hypothesis of lipomatosis of the cecal appendix." + ] + }, + { + "id": "multiclinsum_test_393_en.txt", + "fulltext": "A 68-year-old woman presented with right-sided abdominal pain. Contrast-enhanced CT revealed an 86 mm tumor in the right retroperitoneal space that extended into the IVC; superiorly, it reached the right atrium, and inferiorly, it extended to the confluence of the iliac veins . On chest and abdominal CT, no findings suggestive of metastasis were observed. Percutaneous needle biopsy confirmed a diagnosis of leiomyosarcoma. Echocardiography revealed tumors in the IVC and atrium; however, adhesions could not be definitively assessed. We conducted cine MRI to assess tumor invasion into the IVC wall. The cine MRI comprised two different types of steady-state free precession images, and the parameter details are presented in Table . Cine MRI demonstrated that the uppermost part of the tumor was located within the right atrium; this part of the tumor exhibited mobility and was not adherent to the right atrial wall. Furthermore, we observed blood flow between the tumor and the intraluminal wall of the upper segment of the IVC, and no adhesions were detected . Based on these findings, tumor resection was considered feasible.\nThe surgery was performed via an abdominal approach. The tumor was contiguous with the IVC inferior to the renal vein. Following a diaphragmatic incision, palpation of the IVC near the right atrium revealed the mobility of the intravascular tumor. This affirmed our pre-surgical predictions. The tumor's adherence to the right kidney necessitated en bloc resection. Clamping sites were obtained as shown in Figure , with the upper IVC clamp achieved by manually pressing down the tumor. After clamping, blood pressure remained stable at around 110/90 mmHg. The IVC inferior to the renal vein was strongly adherent to the tumor, so it was resected together, while the tumor superior to the renal vein was withdrawn. The artificial vascular replacement was performed from the inferior border of the left renal vein to the bifurcation. The operative time was 628 min, and the blood loss was 2750 mL.\nThe final histopathological diagnosis revealed pleomorphic leiomyosarcoma with a Ki-67 index of 60% and negative margins. Some areas exhibited identifiable smooth muscle characteristics, while other regions were notably pleomorphic, suggesting highly undifferentiated zones. CT on postoperative Day 49 showed tumor recurrence in the right retroperitoneum. The subsequent CT on postoperative Day 65 showed metastases in the lung, liver, and right ischium. The patient died on postoperative Day 106.", + "fulltext_subclaims": [ + "The patient is a 68-year-old woman.", + "The patient presented with right-sided abdominal pain.", + "Contrast-enhanced CT revealed an 86 mm tumor in the right retroperitoneal space.", + "The tumor extended into the IVC.", + "The tumor reached the right atrium superiorly.", + "The tumor extended to the confluence of the iliac veins inferiorly.", + "No findings suggestive of metastasis were observed on chest and abdominal CT.", + "Percutaneous needle biopsy confirmed a diagnosis of leiomyosarcoma.", + "Echocardiography revealed tumors in the IVC and atrium.", + "Adhesions could not be definitively assessed on echocardiography.", + "Cine MRI was conducted to assess tumor invasion into the IVC wall.", + "The cine MRI comprised two different types of steady-state free precession images.", + "The uppermost part of the tumor was located within the right atrium.", + "The uppermost part of the tumor exhibited mobility.", + "The uppermost part of the tumor was not adherent to the right atrial wall.", + "Blood flow between the tumor and the intraluminal wall of the upper segment of the IVC was observed.", + "No adhesions were detected.", + "Tumor resection was considered feasible.", + "The surgery was performed via an abdominal approach.", + "The tumor was contiguous with the IVC inferior to the renal vein.", + "A diaphragmatic incision was made.", + "Palpation of the IVC near the right atrium revealed the mobility of the intravascular tumor.", + "The tumor's adherence to the right kidney necessitated en bloc resection.", + "Clamping sites were obtained.", + "The upper IVC clamp was achieved by manually pressing down the tumor.", + "Blood pressure remained stable at around 110/90 mmHg after clamping.", + "The IVC inferior to the renal vein was strongly adherent to the tumor.", + "The IVC inferior to the renal vein was resected together with the tumor.", + "The tumor superior to the renal vein was withdrawn.", + "Artificial vascular replacement was performed from the inferior border of the left renal vein to the bifurcation.", + "The operative time was 628 minutes.", + "The blood loss was 2750 mL.", + "The final histopathological diagnosis revealed pleomorphic leiomyosarcoma.", + "The Ki-67 index was 60%.", + "The margins were negative.", + "Some areas exhibited identifiable smooth muscle characteristics.", + "Other regions were notably pleomorphic.", + "CT on postoperative Day 49 showed tumor recurrence in the right retroperitoneum.", + "CT on postoperative Day 65 showed metastases in the lung, liver, and right ischium.", + "The patient died on postoperative Day 106." + ], + "summary": "A 68-year-old woman presented with right-sided abdominal pain. Computed tomography revealed an 86 mm tumor in the right retroperitoneal space that extended into the inferior vena cava and reached superiorly to the right atrium. Percutaneous needle biopsy confirmed leiomyosarcoma. Cine magnetic resonance imaging demonstrated no adhesions between the tumor and the upper segment of inferior vena cava wall, nor with the right atrial wall, indicating resectability. Radical tumor resection was successfully performed without requiring thoracotomy.", + "summary_subclaims": [ + "The patient is a 68-year-old woman.", + "The patient presented with right-sided abdominal pain.", + "Computed tomography revealed an 86 mm tumor in the right retroperitoneal space.", + "The tumor extended into the inferior vena cava.", + "The tumor reached superiorly to the right atrium.", + "Percutaneous needle biopsy confirmed leiomyosarcoma.", + "Cine magnetic resonance imaging demonstrated no adhesions between the tumor and the upper segment of inferior vena cava wall.", + "Cine magnetic resonance imaging demonstrated no adhesions between the tumor and the right atrial wall.", + "The tumor was resectable.", + "Radical tumor resection was successfully performed.", + "Radical tumor resection was performed without requiring thoracotomy." + ] + }, + { + "id": "multiclinsum_test_1312_en.txt", + "fulltext": "A 57-year-old Caucasian woman was originally diagnosed with invasive ductal carcinoma in her right breast in February 2011 (ER-positive, PR-positive and HER2-negative). She was also diagnosed as carrying a mutation of BRCA 2. The patient underwent bilateral mastectomy and right-sided sentinel lymph node biopsy with 1 of 6 lymph nodes being found to be positive for metastasis. Unfortunately, she declined adjuvant chemotherapy and radiation recommended by her treating physicians, but only received adjuvant hormonal therapy with letrozole. In February 2012, she presented with renal failure and severe bony pain, and was found to have hypercalcemia with extensive osseous metastasis. CT-guided biopsy of one of the pelvic lesions revealed metastatic adenocarcinoma, consistent with her ER-positive primary breast cancer. The patient received aggressive hydration and denosumab for hypercalcemia. She also received radiation to her sacrum and bilateral sacroiliac joints to palliate her pain. The patient was enrolled in a clinical trial, receiving hormonal therapy with the combination of tamoxifen and metformin. Her monthly denosumab injection for bone metastasis was also continued. Unfortunately, her disease continued to progress, and she was found to have extensive lymphadenopathy involving the cervical, mediastinal and pelvic area. In January 2013, the patient was transferred to our center.\nAs breast cancer in BRCA mutation carriers has been previously shown to respond to platinum-based chemotherapy , treatment with single-agent carboplatin (AUC 5) was initiated. Three days after starting carboplatin, the patient developed a severe headache and projectile vomiting. An MRI of her brain revealed a large, dura-based, contrast-enhancing extra-axial mass, approximately 3.3 × 4.3 cm in size, causing severe vasogenic edema in the right frontotemporal region, resulting in a significant midline shift. She was seen by a neurosurgeon, and an emergent decompressive craniotomy was performed. The pathology of the resected mass was consistent with metastatic breast cancer. Postoperative brain MRI showed marked improvement, but unfortunately it also demonstrated some small dura-based masses over the left cerebral hemispheres. The patient recovered quickly and subsequently received whole-brain radiation therapy to treat dural metastases. Despite the delay of systemic therapy for almost 2 months due to craniotomy and radiation, her extra-cranial disease responded well radiographically to the first dose of carboplatin, and thus this agent was continued until June 2013.\nAt this time, PET-CT showed a progression of the disease in the cervical, mediastinal and retroperitoneal lymph nodes. Carboplatin was discontinued and PLD was initiated as a second-line chemotherapy. For the first cycle, a total of 85 mg (40 mg/m2) of liposomal doxorubicin in 250 ml of D5W (5% glucose solution) was prescribed with the same premedications used for the prior carboplatin. PLD was infused at a rate of 1 mg/min for the first 20 min. As no infusion-related adverse effects were observed, the rate was increased to 1.6 mg/min in order to complete the infusion over 1 hour according to our standard protocol. Twenty minutes later (approximately 50 mg PLD in total was given), the patient was noted to develop confusion. She had some tangential thoughts, started to make nonsensical comments to the people around her and began to tell stories from the past. The infusion was held and she was observed for 30 min, but her symptoms did not improve. An on-call physician was contacted to assess her. She was found to be alert and oriented and also able to answer questions appropriately. There were no neurological deficits. As the patient had an MRI earlier that day, no further imaging studies were performed. The infusion was discontinued due to the mental status change, and the patient was observed closely. Her symptoms persisted for 18 h and then resolved spontaneously. The patient's acute transient encephalopathy was deemed secondary to PLD. When she returned for the second cycle of chemotherapy, she was not rechallenged with PLD; instead, she was being administered conventional doxorubicin. This agent was tolerated well without any mental status change for another 5 months. Unfortunately, the patient developed a disease progression, requiring further palliative therapy with an eventual transfer to a hospice service, where she died 2 months later.", + "fulltext_subclaims": [ + "The patient was originally diagnosed with invasive ductal carcinoma in her right breast in February 2011.", + "The tumor was ER-positive, PR-positive and HER2-negative.", + "The patient was diagnosed as carrying a mutation of BRCA 2.", + "She underwent bilateral mastectomy and right-sided sentinel lymph node biopsy.", + "One of 6 lymph nodes was found to be positive for metastasis.", + "She declined adjuvant chemotherapy and radiation.", + "She received adjuvant hormonal therapy with letrozole.", + "In February 2012, she presented with renal failure and severe bony pain.", + "She was found to have hypercalcemia with extensive osseous metastasis.", + "CT-guided biopsy of one of the pelvic lesions revealed metastatic adenocarcinoma.", + "The metastatic adenocarcinoma was consistent with her ER-positive primary breast cancer.", + "She received aggressive hydration and denosumab for hypercalcemia.", + "She received radiation to her sacrum and bilateral sacroiliac joints.", + "She was enrolled in a clinical trial receiving hormonal therapy with the combination of tamoxifen and metformin.", + "Her monthly denosumab injection for bone metastasis was continued.", + "Her disease continued to progress.", + "She was found to have extensive lymphadenopathy involving the cervical, mediastinal and pelvic area.", + "In January 2013, the patient was transferred to our center.", + "Treatment with single-agent carboplatin (AUC 5) was initiated.", + "Three days after starting carboplatin, the patient developed a severe headache and projectile vomiting.", + "An MRI of her brain revealed a large, dura-based, contrast-enhancing extra-axial mass.", + "The mass was approximately 3.3 × 4.3 cm in size.", + "The mass caused severe vasogenic edema in the right frontotemporal region.", + "The mass caused a significant midline shift.", + "An emergent decompressive craniotomy was performed.", + "The pathology of the resected mass was consistent with metastatic breast cancer.", + "Postoperative brain MRI showed marked improvement.", + "Postoperative brain MRI also demonstrated some small dura-based masses over the left cerebral hemispheres.", + "The patient received whole-brain radiation therapy to treat dural metastases.", + "Her extra-cranial disease responded well radiographically to the first dose of carboplatin.", + "Carboplatin was continued until June 2013.", + "PET-CT showed a progression of the disease in the cervical, mediastinal and retroperitoneal lymph nodes.", + "Carboplatin was discontinued and PLD was initiated as a second-line chemotherapy.", + "A total of 85 mg (40 mg/m2) of liposomal doxorubicin in 250 ml of D5W was prescribed.", + "PLD was infused at a rate of 1 mg/min for the first 20 min.", + "The rate was increased to 1.6 mg/min.", + "The infusion was to be completed over 1 hour.", + "Twenty minutes later, the patient was noted to develop confusion.", + "She had some tangential thoughts and started to make nonsensical comments.", + "The infusion was held.", + "She was observed for 30 min, but her symptoms did not improve.", + "An on-call physician was contacted.", + "She was found to be alert and oriented.", + "She was able to answer questions appropriately.", + "There were no neurological deficits.", + "No further imaging studies were performed.", + "The infusion was discontinued due to the mental status change.", + "Her symptoms persisted for 18 h and then resolved spontaneously.", + "The patient's acute transient encephalopathy was deemed secondary to PLD.", + "When she returned for the second cycle of chemotherapy, she was not rechallenged with PLD.", + "She was administered conventional doxorubicin.", + "This agent was tolerated well without any mental status change for another 5 months.", + "The patient developed a disease progression.", + "She required further palliative therapy.", + "She was transferred to a hospice service.", + "She died 2 months later." + ], + "summary": "A 57-year-old female patient with metastatic breast cancer developed dural metastases to the brain and underwent craniotomy and whole-brain radiation. She continued to receive chemotherapy with carboplatin without any serious complications. Four months later, there was evidence of progression leading to the institution of PLD. During the first course of PLD, there was evidence of acute encephalopathy which resolved after 18 h with discontinuation of this agent. Interestingly, she did well when she was rechallenged with conventional doxorubicin in the following cycles.", + "summary_subclaims": [ + "The patient is a 57-year-old female.", + "The patient had metastatic breast cancer.", + "The patient developed dural metastases to the brain.", + "The patient underwent craniotomy.", + "The patient received whole-brain radiation.", + "The patient continued to receive chemotherapy with carboplatin.", + "There were no serious complications from the chemotherapy.", + "Four months later, there was evidence of progression.", + "PLD was instituted.", + "During the first course of PLD, there was evidence of acute encephalopathy.", + "The acute encephalopathy resolved after 18 h.", + "The acute encephalopathy resolved after discontinuation of PLD.", + "The patient was rechallenged with conventional doxorubicin in the following cycles.", + "The patient did well when rechallenged with conventional doxorubicin." + ] + }, + { + "id": "multiclinsum_test_258_en.txt", + "fulltext": "A 46-year-old obese woman presented to an outside hospital in August of 2005 with significant abdominal pain and diarrhea. Computed tomography (CT) revealed a 17 × 13 cm mass in the left upper quadrant that appeared to arise from the body and tail of the pancreas. The patient was taken to the operating room at an outside institution, but the mass was deemed unresectable due to reported involvement of the SMA, stomach, and colon. Wedge biopsy of the mass was consistent with pancreatic VIPoma. Over the next 2 years, the patient was treated with long-acting somatostatin with some improvement in her symptoms. The patient, however, developed repeat episodes of upper and lower gastrointestinal bleeding with associated anemia and ongoing transfusion requirements. Repeat CT scan revealed thrombosis of the splenic vein with numerous large splenic and gastric varices consistent with sinistral portal hypertension. In the summer of 2007, the patient underwent a failed transjugular intrahepatic portosystemic shunt (TIPS) procedure at an outside institution. The patient was therefore referred to the Johns Hopkins Department of Interventional Radiology for variceal embolization.\nThe patient's case was reviewed at the Johns Hopkins multi-disciplinary pancreas tumor board. A repeat three-dimensional (3-D) pancreas protocol CT scan revealed an 18 × 12 cm mass abutting the liver, stomach, spleen, left adrenal, colon and invading the distal duodenum – proximal jejunum at the ligament of Treitz. The splenic vein was occluded. Large collateral vessels surrounded the mass and were associated with extensive gastric collaterals . The mass displaced the SMA and SMV, but these vessels were patent and uninvolved . As such, there were no obvious contraindications to resection and surgery was recommended.\nGiven the size of the mass and the associated extensive varices, the patient underwent preoperative proximal splenic artery embolization . Twenty-four hours following this, the patient was taken to surgery where she was found to have a very large mass arising from the body and tail of the pancreas that invaded the left diaphragm, stomach, left adrenal, fourth portion of the duodenum – first portion of the jejunum, transverse colon, and spleen. In order to better expose the SMV at the inferior border of the pancreatic neck, the right colon and root of the small bowel mesentery were mobilized in the fashion of Cattell and Braasch. The SMA medial to the SMV was exposed as it coursed into the small bowel mesentery. The tumor was noted to closely abut and displace both the SMV and SMA, but the vessels were not encased. After developing the retro-pancreatic plane over the SMV – portal vein, the pancreatic neck was transected. The mass was subsequently resected en bloc with a portion of the left diaphragm, entire stomach, spleen, left adrenalectomy, fourth portion of the duodenum – proximal jejunum and transverse colon. Gastrointestinal continuity was restored using a Roux-en-Y method with a hand sewn end-to-side esophago-jejunostomy, a duodeno-jejuneal anastomsis (50 cm distally), and a stapled colo-colonic anastomosis. The pancreatic remnant was closed with pledgeted sutures. Estimated blood loss was 500 ml. Final pathology confirmed a VIPoma originating from the pancreatic body with invasion of the stomach, spleen, small bowel, and colon . All margins were uninvolved by tumor. The patient is alive and disease-free.\nThe patient tolerated the procedure well. On post-operative day four, a swallow study demonstrated a normal post-surgical esophago-jejunal anastomosis with no evidence of leak. The patient was discharged home on post-operative day ten tolerating a post-gastrectomy diet. She received no adjuvant therapy and is currently alive and disease-free at 6 months of follow-up.", + "fulltext_subclaims": [ + "The patient is a 46-year-old obese woman.", + "She presented in August of 2005 with significant abdominal pain and diarrhea.", + "Computed tomography (CT) revealed a 17 × 13 cm mass in the left upper quadrant.", + "The mass appeared to arise from the body and tail of the pancreas.", + "The mass was deemed unresectable due to reported involvement of the SMA, stomach, and colon.", + "Wedge biopsy of the mass was consistent with pancreatic VIPoma.", + "The patient was treated with long-acting somatostatin.", + "The patient developed repeat episodes of upper and lower gastrointestinal bleeding.", + "Repeat CT scan revealed thrombosis of the splenic vein.", + "The patient underwent a failed transjugular intrahepatic portosystemic shunt (TIPS) procedure in the summer of 2007.", + "A repeat three-dimensional (3-D) pancreas protocol CT scan revealed an 18 × 12 cm mass.", + "The mass abutted the liver, stomach, spleen, left adrenal, colon, and invaded the distal duodenum – proximal jejunum.", + "The splenic vein was occluded.", + "Large collateral vessels surrounded the mass.", + "The mass displaced the SMA and SMV, but these vessels were patent and uninvolved.", + "There were no obvious contraindications to resection.", + "The patient underwent preoperative proximal splenic artery embolization.", + "The patient was found to have a very large mass arising from the body and tail of the pancreas.", + "The tumor invaded the left diaphragm, stomach, left adrenal, fourth portion of the duodenum – first portion of the jejunum, transverse colon, and spleen.", + "The right colon and root of the small bowel mesentery were mobilized in the fashion of Cattell and Braasch.", + "The SMA medial to the SMV was exposed as it coursed into the small bowel mesentery.", + "The tumor closely abutted and displaced both the SMV and SMA, but the vessels were not encased.", + "The pancreatic neck was transected after developing the retro-pancreatic plane over the SMV – portal vein.", + "The mass was resected en bloc with a portion of the left diaphragm, entire stomach, spleen, left adrenalectomy, fourth portion of the duodenum – proximal jejunum, and transverse colon.", + "Gastrointestinal continuity was restored using a Roux-en-Y method.", + "The pancreatic remnant was closed with pledgeted sutures.", + "Estimated blood loss was 500 ml.", + "Final pathology confirmed a VIPoma originating from the pancreatic body.", + "The tumor invaded the stomach, spleen, small bowel, and colon.", + "All margins were uninvolved by tumor.", + "The patient is alive and disease-free.", + "A swallow study on post-operative day four demonstrated a normal post-surgical esophago-jejunal anastomosis.", + "The patient was discharged home on post-operative day ten.", + "She received no adjuvant therapy.", + "She is currently alive and disease-free at 6 months of follow-up." + ], + "summary": "A 46 year old women presented with abdominal pain and diarrhea. A three-dimensional (3-D) pancreas protocol computed tomography scan revealed an 18 x 12 cm pancreatic VIPoma abutting the liver, stomach, spleen, left adrenal, colon that also invaded the distal duodenum - proximal jejunum at the ligament of Treitz in association with sinistral portal hypertension. Following preoperative proximal splenic artery embolization, the patient with underwent successful en bloc resection of the locally advanced VIPoma in conjunction with a diaphragmatic resection, total gastrectomy, splenectomy, left adrenalectomy, as well as small and large bowel resection. The estimated blood loss was 500 ml. All margins were negative (R0 resection). The patient is alive and disease-free.", + "summary_subclaims": [ + "A 46 year old women presented with abdominal pain and diarrhea.", + "A three-dimensional (3-D) pancreas protocol computed tomography scan revealed an 18 x 12 cm pancreatic VIPoma abutting the liver, stomach, spleen, left adrenal, colon.", + "The pancreatic VIPoma also invaded the distal duodenum - proximal jejunum at the ligament of Treitz.", + "The pancreatic VIPoma was associated with sinistral portal hypertension.", + "Following preoperative proximal splenic artery embolization, the patient underwent successful en bloc resection of the locally advanced VIPoma.", + "The en bloc resection was in conjunction with a diaphragmatic resection, total gastrectomy, splenectomy, left adrenalectomy, as well as small and large bowel resection.", + "The estimated blood loss was 500 ml.", + "All margins were negative (R0 resection).", + "The patient is alive and disease-free." + ] + }, + { + "id": "multiclinsum_test_852_en.txt", + "fulltext": "A male patient, 2 years old, was admitted to the hospital on May 21, 2018 due a sustained fever of over 6 consecutive days, with his highest body temperature reaching 39.0 °C, which peaked once or twice per day, accompanied by coughing, phlegm, and shortness of breath. His local hospital diagnosed him with “acute upper respiratory tract infection” and prescribed him 5 days of Chinese herb medicine; however, his temperature was not alleviated. After entering our hospital, his chest X-ray showed that both of his lungs had an increased thickened texture. With possible inflammation suspected, the boy was then admitted as a pneumonia patient. Prior to the onset of the illness, the child’s spirit was normal, with no irritability or fatigue. His dietary intake was also normal, with normal appearing defecation. His medical history showed that he was a rather healthy baby, G1P1 (Gravida 1, Para 1) full-term delivery. He was breastfed and had normal growth and development for his age, and his parents were also healthy. As a child, he had no history of food or drug allergies reported, and no oral diuretics or catharsis drugs were taken previously. However, the child had a history of spontaneous night-sweats and enuresis according to his parents.\nBody temperature 37.0 °C, pulse 125 beats/min, breathing 25 breaths/min, blood pressure 95/65 mmHg, weight 10.5 kg, height 92 cm, slightly underweight (boy standard weight: 11.2–14.0 kg). Normal reflexes without shortness of breath or cyanosis. No rash, no swelling of superficial lymph nodes, pharyngeal hyperaemia. Bilateral tonsils were not enlarged. Rough tracheal sounds with phlegm rales were heard. Heart and abdominal examinations were normal. Extremities and spine were normal, physiological reflexes existed, and pathological reflexes were not elicited.\nBlood test showed WBC 14.85 × 109/L, N% 78.2, L% 14.6, HGB141 g/L, PLT 290 × 109/L, CRP10.0 mg/L. Stool and urine routines were normal; procalcitonin 0.3 ng/L; ESR 15 mm/h; ferritin 90.8 ng/ml; ASO normal; Mycoplasma pneumoniae antibody IgM negative. Liver and kidney function, glucose, coagulation function, rheumatoid index, thyroid function, lymphocyte subtype tests (NK cells, T cells, auxiliary T cells, reactive T cells, B cells) and immunoglobulins all met the reference ranges of his age group; repeated examinations of electrolytes indicated hypokalaemia, hypomagnesemia, low chlorine, low sodium and transient mild metabolic alkalosis (see Table for details). A further check of the 24-h urinary potassium was 57 mmol/24 h, and the 24-h urinary calcium was 2.86 mmol/24 h, which informed increased urinary potassium level; plasma renin activity was 142.05 pg/ml (4–24 pg/ml); angiotensin II was 435.62 pg/ml (25–129 pg/ml); aldosterone was 100.26 pg/ml (10–160 pg/ml); and serum cortisol and adrenocorticotropic hormone were normal. Multiple reviews of ECG and 24-h Holter showed 1st degree atrioventricular block (see Table for details), cardiac colour Doppler showed tricuspid valve, mild regurgitation of the pulmonary valve; abdominal colour Doppler showed intrahepatic calcification plaque and accumulation of gas in the colon; renal colour Doppler ultrasound and adrenal colour Doppler ultrasound did not appear abnormal.\nAccording to the symptoms, signs and chest radiographs of the child, he could be diagnosed with pneumonia. Analysis of pathogens and blood test results showed a high total number of white blood cells. Neutrophils were dominant, along with high CRP and PCT. According to the infection index combined with our clinical experience, these findings indicate the high possibility of bacterial infection. At the beginning of the treatment, intravenous ceftriaxone (80 mg/kg) was prescribed to treat the infection and to suppress coughing and phlegm with airway management. His body temperature dropped to normal within 24 h, which suggested the antibiotic was effective. On the day of admission, the emergency reports showed electrolyte values with “blood potassium 1.7 mmol/L” and “blood magnesium 0.59 mmol/L”. First, we considered the possibility of electrolyte imbalance secondary to pneumonia; thus, oral and intravenous potassium supplementation (4–5 g/day) were prescribed along with injection of magnesium sulphate and rehydration treatment. Regular review of electrolytes showed that blood potassium gradually increased to 3.1 mmol/L within 2–3 days; however, the result could not be sustained, and it was difficult to make it continue to rise. From further questioning of the child’s medical history according to the parents, it was learned that the child had long-term “sleepiness,” “drowsiness” and other symptoms accompanied by enuresis (3–4 times/week) and severe night sweats (parents described it as “like a shower”); he was also slightly light in weight. All of the above could have been due to possible chronic potassium loss. With persistent hypokalaemia and hypomagnesemia observed in the clinical stay, his urinary potassium excretion increased, and his urinary calcium was normal. The blood biochemical analysis showed that the PH and HCO3- were high. His blood pressure was normal, but plasma renin activity and angiotensin were high. The aldosterone levels were normal, and the clinical consideration of “Gitelman syndrome” was likely. Further second-generation gene analysis (KingMed Diagnostics) (see Figs. and for details) detected two heterozygous mutations (SLC12A3 (16q13/NM-000339.2)): exon number Exon12, cDNA level 1456G > A, protein level Asp486Asn, considering that the disease gene was derived from the mother; and exon No. Intron12, cDNA level 602-16G > A, protein levels were normal, considering a suspicious pathogenicity derived from the father. With the Gitelman syndrome diagnosis having been established, long-term oral potassium citrate granules were prescribed to be taken for 1 year. Blood potassium levels were stable between 3.1–3.5 mmol/L, and the PR intervals were between 0.17–0.2 cm. Growth and development were normal, and the enuresis disappeared, but the night sweats still persisted.", + "fulltext_subclaims": [ + "The patient is a 2-year-old male.", + "The patient was admitted on May 21, 2018.", + "The patient had a fever lasting over 6 consecutive days.", + "The highest body temperature recorded was 39.0 °C.", + "The fever peaked once or twice per day.", + "The patient had coughing.", + "The patient had phlegm.", + "The patient had shortness of breath.", + "The local hospital diagnosed the patient with “acute upper respiratory tract infection.”", + "The patient was prescribed 5 days of Chinese herb medicine.", + "The patient’s temperature was not alleviated.", + "The chest X-ray showed both lungs had an increased thickened texture.", + "The boy was admitted as a pneumonia patient.", + "The child’s spirit was normal prior to the onset of the illness.", + "The child had no irritability or fatigue.", + "The child’s dietary intake was normal.", + "The child’s medical history showed he was a healthy baby.", + "The child was a G1P1 full-term delivery.", + "The child was breastfed.", + "The child had normal growth and development for his age.", + "The parents were healthy.", + "The child had no history of food or drug allergies.", + "The child had no prior use of oral diuretics or catharsis drugs.", + "The child had a history of spontaneous night-sweats.", + "The child had a history of enuresis.", + "The body temperature was 37.0 °C.", + "The pulse was 125 beats/min.", + "The breathing rate was 25 breaths/min.", + "The blood pressure was 95/65 mmHg.", + "The weight was 10.5 kg.", + "The height was 92 cm.", + "The child was slightly underweight.", + "The reflexes were normal.", + "There was no shortness of breath or cyanosis.", + "There was no rash.", + "There was no swelling of superficial lymph nodes.", + "The pharynx showed hyperaemia.", + "The bilateral tonsils were not enlarged.", + "Rough tracheal sounds with phlegm rales were heard.", + "The heart and abdominal examinations were normal.", + "The extremities and spine were normal.", + "Physiological reflexes existed.", + "Pathological reflexes were not elicited.", + "The white blood cell count was 14.85 × 109/L.", + "The neutrophil percentage was 78.2%.", + "The lymphocyte percentage was 14.6%.", + "The hemoglobin was 141 g/L.", + "The platelet count was 290 × 109/L.", + "The C-reactive protein was 10.0 mg/L.", + "The procalcitonin was 0.3 ng/L.", + "The ESR was 15 mm/h.", + "The ferritin was 90.8 ng/ml.", + "The Mycoplasma pneumoniae antibody IgM was negative.", + "The 24-h urinary potassium was 57 mmol/24 h.", + "The 24-h urinary calcium was 2.86 mmol/24 h.", + "The plasma renin activity was 142.05 pg/ml.", + "The angiotensin II was 435.62 pg/ml.", + "The aldosterone was 100.26 pg/ml.", + "The ECG showed 1st degree atrioventricular block.", + "The cardiac colour Doppler showed tricuspid valve and mild pulmonary valve regurgitation.", + "The abdominal colour Doppler showed intrahepatic calcification plaque.", + "The renal and adrenal colour Doppler ultrasounds did not appear abnormal.", + "The child was diagnosed with pneumonia.", + "The blood test showed a high total number of white blood cells.", + "Neutrophils were dominant.", + "The CRP and PCT were high.", + "The findings indicated a high possibility of bacterial infection.", + "Intravenous ceftriaxone (80 mg/kg) was prescribed.", + "The body temperature dropped to normal within 24 h.", + "The emergency reports showed blood potassium 1.7 mmol/L.", + "The emergency reports showed blood magnesium 0.59 mmol/L.", + "Oral and intravenous potassium supplementation were prescribed.", + "Intravenous magnesium sulphate was administered.", + "Blood potassium gradually increased to 3.1 mmol/L within 2–3 days.", + "The blood potassium result could not be sustained.", + "The child had long-term sleepiness.", + "The child had long-term drowsiness.", + "The child had enuresis 3–4 times/week.", + "The child had severe night sweats.", + "The child was slightly light in weight.", + "The clinical consideration was Gitelman syndrome.", + "Second-generation gene analysis detected two heterozygous mutations in SLC12A3.", + "The mutations were cDNA level 1456G > A and 602-16G > A.", + "The disease gene was considered derived from the mother.", + "The suspicious pathogenicity was considered derived from the father.", + "Long-term oral potassium citrate granules were prescribed.", + "The blood potassium levels were stable between 3.1–3.5 mmol/L.", + "The PR intervals were between 0.17–0.2 cm.", + "The growth and development were normal.", + "The enuresis disappeared.", + "The night sweats still persisted." + ], + "summary": "This article reports on a 2-year-old boy with severe hypokalaemia who was diagnosed with pneumonia. The child's lab findings were low blood potassium minimum level of 1.7 mmol/L, hypomagnesemia, and metabolic alkalosis. However, he was without the common features of hypokalaemia, such as respiratory paralysis, severe arrhythmia, weakness and decreased blood pressure. After recovering from pneumonia, his potassium levels did not return to normal. This outcome was suspected to be due to chronic renal loss of potassium. After undergoing second-generation gene sequencing tests, it was discovered he carried the SLC12A3 gene mutation with an Asp486Asn mutation site, which he had inherited from his mother. The final diagnosis was made, confirming the child suffered from Gitelman syndrome.", + "summary_subclaims": [ + "The patient is a 2-year-old boy.", + "The patient had severe hypokalaemia.", + "The patient was diagnosed with pneumonia.", + "The child's lab findings showed a low blood potassium minimum level of 1.7 mmol/L.", + "The child had hypomagnesemia.", + "The child had metabolic alkalosis.", + "The child was without the common features of hypokalaemia, such as respiratory paralysis.", + "The child was without the common features of hypokalaemia, such as severe arrhythmia.", + "The child was without the common features of hypokalaemia, such as weakness.", + "The child was without the common features of hypokalaemia, such as decreased blood pressure.", + "After recovering from pneumonia, his potassium levels did not return to normal.", + "This outcome was suspected to be due to chronic renal loss of potassium.", + "After undergoing second-generation gene sequencing tests, it was discovered he carried the SLC12A3 gene mutation.", + "The mutation site was Asp486Asn.", + "The mutation was inherited from his mother.", + "The final diagnosis was Gitelman syndrome." + ] + }, + { + "id": "multiclinsum_test_1364_en.txt", + "fulltext": "A 3-week-old girl, with a family history of maternal unilateral retinoblastoma, presented for evaluation of leukocoria right eye (OD). On examination, visual acuity was fix and follow in both eyes (OU) and intraocular pressures were normal OU. External examination documented obvious leukocoria OD. Fundus evaluation OD revealed a white macular tumor measuring 16.0 mm in largest basal dimension and 6.1 mm in thickness, and with overlying mild vitreous seeding and surrounding extensive serous retinal detachment. Fundus evaluation of the left eye (OS) detected a solitary mass measuring 2.0 mm in basal dimension and 1.0 mm in thickness, located within 2.0 mm from the foveola. A diagnosis of bilateral familial retinoblastoma, group D OD and group B OS, was rendered and treatment with intravenous chemoreduction (CRD) using vincristine, etoposide, and carboplatin was initiated. Following therapy with individual tumor consolidation, all retinoblastomas were regressed.\nAt 6-months follow-up, the right eye remained under control, but the left eye revealed a subtle recurrence of the juxtafoveal tumor and HH-OCT (iVue Optovue, Fremont, CA) revealed an intact macula with adjacent tumor recurrence , measuring 2750 µm in diameter and 792 µm in thickness. The recurrence was 615 µm from the foveola. Treatment with intraarterial chemotherapy (IAC) using Melphalan 5 mg was performed and complete tumor control was achieved with 1 cycle , leaving a concave scar of 2750 µm in diameter and 120 µm in thickness, located 663 µm from the foveola. In addition, there was underlying choroidal thinning and preservation of the foveal microanatomy documented by HH-OCT OS . The findings remained stable on last follow-up at 2 years following IAC.", + "fulltext_subclaims": [ + "The patient is a 3-week-old girl.", + "The patient has a family history of maternal unilateral retinoblastoma.", + "The patient presented for evaluation of leukocoria right eye (OD).", + "Visual acuity was fix and follow in both eyes (OU).", + "Intraocular pressures were normal OU.", + "Fundus evaluation OD revealed a white macular tumor measuring 16.0 mm in largest basal dimension.", + "The tumor in the right eye had overlying mild vitreous seeding.", + "The tumor in the right eye had surrounding extensive serous retinal detachment.", + "Fundus evaluation of the left eye (OS) detected a solitary mass measuring 2.0 mm in basal dimension.", + "The left eye tumor was located within 2.0 mm from the foveola.", + "A diagnosis of bilateral familial retinoblastoma was rendered.", + "The right eye was classified as group D.", + "The left eye was classified as group B.", + "Treatment with intravenous chemoreduction (CRD) using vincristine, etoposide, and carboplatin was initiated.", + "Following therapy with individual tumor consolidation, all retinoblastomas were regressed.", + "At 6-months follow-up, the right eye remained under control.", + "The left eye revealed a subtle recurrence of the juxtafoveal tumor.", + "HH-OCT revealed an intact macula with adjacent tumor recurrence.", + "The recurrence measured 2750 µm in diameter.", + "The recurrence measured 792 µm in thickness.", + "The recurrence was 615 µm from the foveola.", + "Treatment with intraarterial chemotherapy (IAC) using Melphalan 5 mg was performed.", + "Complete tumor control was achieved with 1 cycle.", + "The scar left by the treatment was 2750 µm in diameter.", + "The scar left by the treatment was 120 µm in thickness.", + "The scar was located 663 µm from the foveola.", + "There was underlying choroidal thinning documented by HH-OCT OS.", + "Preservation of the foveal microanatomy was documented by HH-OCT OS.", + "The findings remained stable on last follow-up at 2 years following IAC." + ], + "summary": "A 3-week-old girl was diagnosed with bilateral familial retinoblastoma, classified as group D in the right eye (OD) and group B in the left eye (OS), and treated with intravenous chemoreduction. At 6-months follow-up, the right eye was under control, but the left eye revealed a subtle juxtafoveal tumor recurrence, documented on handheld OCT (HH-OCT) and measuring 2750 µm in diameter and 792 µm in thickness. Treatment with intraarterial chemotherapy (IAC) using 1 cycle of melphalan 5 mg was performed and complete tumor control was achieved, leaving a flat, concave scar 663 µm from the intact foveola and measuring 2750 µm in diameter and 120 µm in thickness. Foveal microanatomy OS was preserved on HH-OCT. The findings remained stable at 2 years following IAC.", + "summary_subclaims": [ + "The patient is a 3-week-old girl.", + "She was diagnosed with bilateral familial retinoblastoma.", + "The right eye was classified as group D.", + "The left eye was classified as group B.", + "She was treated with intravenous chemoreduction.", + "At 6-months follow-up, the right eye was under control.", + "The left eye revealed a subtle juxtafoveal tumor recurrence.", + "The recurrence was documented on handheld OCT.", + "The tumor measured 2750 µm in diameter.", + "The tumor measured 792 µm in thickness.", + "Treatment with intraarterial chemotherapy using 1 cycle of melphalan 5 mg was performed.", + "Complete tumor control was achieved.", + "A flat, concave scar was left 663 µm from the intact foveola.", + "The scar measured 2750 µm in diameter.", + "The scar measured 120 µm in thickness.", + "Foveal microanatomy OS was preserved on HH-OCT.", + "The findings remained stable at 2 years following IAC." + ] + }, + { + "id": "multiclinsum_test_3158_en.txt", + "fulltext": "A 27-year-old young adult Ethiopian female patient who is known to have chronic rheumatic valvular heart disease for the past 8 years started to experience repetitive uncontrollable movements of her extremities and trunk since 3 years ago and which were occurring once to three times per month. The abnormal body movements usually lasted up to a week duration and got worse while she tried to sit or walk and improved with rest. She was consistently taking intramuscular injection of benzathine penicillin G 1.2 million units every month for the past 8 years. She did not have previous history of behavioral and emotional lability. She does not remember childhood history of rheumatic fever or movement disorder. She did not use oral or injectable hormonal agents. There was no family history of rheumatic fever, social stress, psychiatric disease, or tic disorders. Upon physical examination, temperature was 36.7°C, heartbeat was 90 beats per minute, and blood pressure was 100/70 mmHg. There was holosystolic murmur at the apical area radiating to the left axilla. Choreiform movements were apparent on all limbs and trunk.\n\nLaboratory investigations revealed moderate leukopenia (but with a normal repeat complete blood count after 3 days), normal liver enzymes, normal renal function tests, erythrocyte sedimentation rate of 37 mm/hour, negative qualitative C-reactive protein, weakly positive anti-streptolysin O antibody, negative qualitative antinuclear antibody, negative urine human chorionic gonadotrophin and normal level of thyroid stimulating hormone. Magnetic resonance imaging of the brain showed left parietal periventricular tiny white matter non-specific lesion. Rheumatic heart involvement was confirmed by echocardiography which showed thickening of mitral valve leaflets with severe mitral regurgitation.\n\nThe present case was diagnosed as recurrent Sydenham chorea based on clinical evidence and she was prescribed valproic acid 500 mg PO/day for 2 weeks and benzathine penicillin G injection was made every 3 weeks. She was re-evaluated after 2 weeks and she had significant improvement with good control of motor activity and reduced involuntary movements of her extremities and trunk. She was then followed every 3 weeks for the subsequent 3 months and she did not have any abnormal body movement. She was finally referred to an advanced cardiac center for possible mitral valve replacement.", + "fulltext_subclaims": [ + "The patient is a 27-year-old young adult Ethiopian female.", + "She has chronic rheumatic valvular heart disease for the past 8 years.", + "She started experiencing repetitive uncontrollable movements of her extremities and trunk 3 years ago.", + "The abnormal body movements occurred once to three times per month.", + "The abnormal body movements lasted up to a week.", + "The abnormal body movements worsened while she tried to sit or walk.", + "The abnormal body movements improved with rest.", + "She was taking intramuscular injection of benzathine penicillin G 1.2 million units every month for the past 8 years.", + "She did not have previous history of behavioral and emotional lability.", + "She did not remember childhood history of rheumatic fever.", + "She did not remember childhood history of movement disorder.", + "She did not use oral or injectable hormonal agents.", + "There was no family history of rheumatic fever.", + "There was no family history of social stress.", + "There was no family history of psychiatric disease.", + "There was no family history of tic disorders.", + "Physical examination showed temperature of 36.7°C.", + "Physical examination showed heartbeat of 90 beats per minute.", + "Physical examination showed blood pressure of 100/70 mmHg.", + "There was holosystolic murmur at the apical area radiating to the left axilla.", + "Choreiform movements were apparent on all limbs and trunk.", + "Laboratory investigations revealed moderate leukopenia.", + "Repeat complete blood count after 3 days was normal.", + "Erythrocyte sedimentation rate was 37 mm/hour.", + "Qualitative C-reactive protein was negative.", + "Anti-streptolysin O antibody was weakly positive.", + "Qualitative antinuclear antibody was negative.", + "Urine human chorionic gonadotrophin was negative.", + "Thyroid stimulating hormone level was normal.", + "Magnetic resonance imaging of the brain showed left parietal periventricular tiny white matter non-specific lesion.", + "Rheumatic heart involvement was confirmed by echocardiography.", + "Echocardiography showed thickening of mitral valve leaflets.", + "Echocardiography showed severe mitral regurgitation.", + "The present case was diagnosed as recurrent Sydenham chorea.", + "Valproic acid 500 mg PO/day was prescribed for 2 weeks.", + "Benzathine penicillin G injection was made every 3 weeks.", + "After 2 weeks, she had significant improvement with good control of motor activity.", + "After 2 weeks, she had reduced involuntary movements of her extremities and trunk.", + "She was followed every 3 weeks for the subsequent 3 months.", + "She did not have any abnormal body movement during the 3-month follow-up.", + "She was referred to an advanced cardiac center for possible mitral valve replacement." + ], + "summary": "A 27-year-old young adult Ethiopian female patient with chronic rheumatic valvular heart disease for the last 8 years experienced repetitive uncontrollable movements of her extremities and torso for three years prior to her current visit. Physical examination was significant for holosystolic murmur at the apical area radiating to the left axilla and choreiform movements apparent on all limbs and trunk. Investigations were significant for mildly raised ESR, echocardiography findings of thickened mitral valve leaflets and severe mitral regurgitation. She was successfully treated with valproic acid and the frequency of penicillin injection was made every 3 weeks with no recurrence for the first 3 months follow-up period.", + "summary_subclaims": [ + "The patient is a 27-year-old young adult Ethiopian female.", + "The patient has chronic rheumatic valvular heart disease for the last 8 years.", + "She experienced repetitive uncontrollable movements of her extremities and torso for three years prior to her current visit.", + "Physical examination was significant for holosystolic murmur at the apical area radiating to the left axilla.", + "Choreiform movements were apparent on all limbs and trunk.", + "Investigations were significant for mildly raised ESR.", + "Echocardiography findings included thickened mitral valve leaflets.", + "Echocardiography findings included severe mitral regurgitation.", + "She was successfully treated with valproic acid.", + "The frequency of penicillin injection was made every 3 weeks.", + "There was no recurrence for the first 3 months follow-up period." + ] + }, + { + "id": "multiclinsum_test_76_en.txt", + "fulltext": "The patient was a 67-year-old man. Esophagogastroduodenoscopy revealed Borrmann type 3 advanced gastric cancer at the pyloric region and abdominal ultrasonography revealed abdominal aortic aneurysm. The patient initially underwent distal gastrectomy and D2 dissection for Borrmann type 3 advanced gastric cancer. One month later, endovascular aortic repair was performed for the abdominal aortic aneurysm. The size of the gastric tumor was 40 × 27 mm, and the pathological report identified tubular adenocarcinoma: tub2 and T2N1M0 stage IIA. Six weeks after gastrectomy, postoperative adjuvant chemotherapy was started with oral TS-1 (120 mg/body; days 1–14 every 3 weeks). Six months later, abdominopelvic computed tomography (CT) showed multiple tumors in liver segments S1 and S7 and partial resection of the caudate lobe and posterior segment was performed. The pathological report showed metastatic adenocarcinoma from gastric cancer and HER-2 positive.\nEight courses of S-1 (120 mg/body; days 1–14 every 3 weeks) and oxaliplatin (80 mg/m2 every 3 weeks) were added after liver resection, but 7 months later, the tumor recurred with multiple liver metastases. Nine courses of paclitaxel (80 mg/m2; days 1, 8, and 15) and ramucirumab (8 mg/kg; days 1 and 15) therapy, three courses of irinotecan (140 mg/m2 every 2 weeks), and four courses of docetaxel (50 mg/m2 every 3 weeks) were added sequentially. Liver metastases temporarily reduced in size, but the tumor enlarged again (a). Nivolumab (3 mg/kg every 2 weeks) was therefore started and the liver metastases displayed a reduction in size after 2 months (b). Administration of nivolumab was continued and the tumor shrank further (c), but the patient suffered from general malaise. The dose interval of nivolumab was gradually increased to every 4, 6, and 8 weeks while liver metastases were monitored by CT.\nAfter 28 months of nivolumab administration, the patient developed cough due to bronchitis and malaise had worsened, so nivolumab was discontinued (a). Two months after discontinuing nivolumab, bronchitis symptoms had improved, but malaise had worsened, blood pressure had decreased, and adrenocorticotropic hormone and cortisol levels had declined. Adrenal insufficiency was diagnosed and steroid therapy was started with hydrocortisone, leading to improvements in general malaise and gradual recovery of adrenocorticotropic hormone and cortisol levels. Moreover, the metastatic tumors shrank further after discontinuation of nivolumab (b). Nine months after discontinuation of nivolumab, CT showed that the liver metastases had almost disappeared (c). Hydrocortisone administration was tapered off and discontinued after 1.5 years of treatment. Currently, as of 3.5 years after discontinuation of nivolumab and 8 years after recurrence of liver metastases, no radiological evidence of recurrence has been identified .", + "fulltext_subclaims": [ + "The patient was a 67-year-old man.", + "Esophagogastroduodenoscopy revealed Borrmann type 3 advanced gastric cancer at the pyloric region.", + "Abdominal ultrasonography revealed abdominal aortic aneurysm.", + "The patient initially underwent distal gastrectomy and D2 dissection for Borrmann type 3 advanced gastric cancer.", + "One month later, endovascular aortic repair was performed for the abdominal aortic aneurysm.", + "The size of the gastric tumor was 40 × 27 mm.", + "The pathological report identified tubular adenocarcinoma: tub2 and T2N1M0 stage IIA.", + "Six weeks after gastrectomy, postoperative adjuvant chemotherapy was started with oral TS-1 (120 mg/body; days 1–14 every 3 weeks).", + "Six months later, abdominopelvic computed tomography (CT) showed multiple tumors in liver segments S1 and S7.", + "Partial resection of the caudate lobe and posterior segment was performed.", + "The pathological report showed metastatic adenocarcinoma from gastric cancer and HER-2 positive.", + "Eight courses of S-1 (120 mg/body; days 1–14 every 3 weeks) and oxaliplatin (80 mg/m2 every 3 weeks) were added after liver resection.", + "Seven months later, the tumor recurred with multiple liver metastases.", + "Nine courses of paclitaxel (80 mg/m2; days 1, 8, and 15) and ramucirumab (8 mg/kg; days 1 and 15) therapy were added.", + "Three courses of irinotecan (140 mg/m2 every 2 weeks) were added.", + "Four courses of docetaxel (50 mg/m2 every 3 weeks) were added.", + "Liver metastases temporarily reduced in size, but the tumor enlarged again.", + "Nivolumab (3 mg/kg every 2 weeks) was therefore started.", + "The liver metastases displayed a reduction in size after 2 months.", + "Administration of nivolumab was continued and the tumor shrank further.", + "The patient suffered from general malaise.", + "The dose interval of nivolumab was gradually increased to every 4, 6, and 8 weeks.", + "After 28 months of nivolumab administration, the patient developed cough due to bronchitis.", + "Malaise had worsened, so nivolumab was discontinued.", + "Two months after discontinuing nivolumab, bronchitis symptoms had improved.", + "Malaise had worsened, blood pressure had decreased, and adrenocorticotropic hormone and cortisol levels had declined.", + "Adrenal insufficiency was diagnosed.", + "Steroid therapy was started with hydrocortisone.", + "The metastatic tumors shrank further after discontinuation of nivolumab.", + "Nine months after discontinuation of nivolumab, CT showed that the liver metastases had almost disappeared.", + "Hydrocortisone administration was tapered off and discontinued after 1.5 years of treatment.", + "Currently, as of 3.5 years after discontinuation of nivolumab and 8 years after recurrence of liver metastases, no radiological evidence of recurrence has been identified." + ], + "summary": "A 67-year-old man diagnosed with advanced gastric cancer and abdominal aortic aneurysm initially underwent distal gastrectomy with D2 dissection. Histological examination revealed tub2 and T2N1M0 stage IIA. One month later, endovascular aneurysm repair was performed. Six weeks after gastrectomy, adjuvant chemotherapy with S-1 was started. Six months later, liver metastases were identified and liver segments S1 and S7 were resected. S-1 and oxaliplatin were added postoperatively, but multiple liver metastases recurred. Paclitaxel and ramucirumab, irinotecan, and docetaxel were administered. Liver metastases showed a temporary reduction in size, then enlarged again. Nivolumab was therefore administered and the liver metastases showed a significant reduction in size. The interval between doses gradually increased due to persistent general fatigue. At 28 months after starting nivolumab therapy, bronchitis and adrenal insufficiency appeared, so treatment was discontinued. As of 3.5 years after cessation of nivolumab immunotherapy, tumor regression continued to be maintained. The patient remains alive as of 8 years after recurrence of liver metastases.", + "summary_subclaims": [ + "The patient is a 67-year-old man.", + "The patient was diagnosed with advanced gastric cancer.", + "The patient had an abdominal aortic aneurysm.", + "The patient initially underwent distal gastrectomy with D2 dissection.", + "Histological examination revealed tub2 and T2N1M0 stage IIA.", + "One month after surgery, endovascular aneurysm repair was performed.", + "Six weeks after gastrectomy, adjuvant chemotherapy with S-1 was started.", + "Six months later, liver metastases were identified.", + "Liver segments S1 and S7 were resected.", + "S-1 and oxaliplatin were added postoperatively.", + "Multiple liver metastases recurred.", + "Paclitaxel and ramucirumab were administered.", + "Irinotecan and docetaxel were administered.", + "Liver metastases showed a temporary reduction in size.", + "Liver metastases enlarged again.", + "Nivolumab was administered.", + "The liver metastases showed a significant reduction in size.", + "The interval between doses gradually increased due to persistent general fatigue.", + "At 28 months after starting nivolumab therapy, bronchitis and adrenal insufficiency appeared.", + "Treatment was discontinued.", + "As of 3.5 years after cessation of nivolumab immunotherapy, tumor regression continued to be maintained.", + "The patient remains alive as of 8 years after recurrence of liver metastases." + ] + }, + { + "id": "multiclinsum_test_1188_en.txt", + "fulltext": "The proband was a 22-year-old Iranian woman (south of Iran, Fars province) with DHP deficiency whose parents are a first-degree cousins. There was not any symptoms in the proband until 20 years of age, when during her first pregnancy, elevated liver enzymes was detected during her routine laboratory evaluations (ALT of 147 U/L, reference range: < 31 U/L, AST of 108 U/L, reference range: < 31 U/L and Alk-P of 350 U/L, reference range: 64–306 U/L). She also had increased level of serum iron of 227 μg/dL, reference range: 50–170 μg/Dl and PT of 14.5 s, reference range: 10.5–11.5 s. A spontaneous abortion happened to her during the first trimester of pregnancy. She was evaluated and tested for autoimmune antibodies in which the negative results excluded autoimmune hepatitis as a disease leading to liver dysfunction. Thereafter, she was presented with bloody vomiting, diarrhea, jaundice, weight loss and bilateral mild mid frequency sensorineural hearing loss. Abdominal and pelvic ultrasonography was in favor of cirrhosis and in liver biopsy cryptogenic cirrhosis was confirmed. The patient was initially diagnosed as having glycogen storage disease by considering the clinical evaluation, and referred to genetic counseling where whole-exome sequencing was conducted to discover the underlying etiology. According to NGS results, for confirming the genotype-phenotype correlation, the patient was referred to evaluate the levels of dihydrothymine and dihydrouracil by HPLC tandem-mass spectrometry in which elevated levels of both were identified in the patient’s urine in comparison with the mean concentration observed in control group’s urine (dihydrothymine (μmol/mmol creatinine): patient = 148, controls = 1.4 ± 1.1 (n = 106), dihydrouracil (μmol/mmol creatinine): patient = 254, controls = 4.9 ± 3.2 (n = 106)). There was no history of such condition in other family members.\nAll exons of protein coding regions and flanking introns belonged to the extracted DNA from the proband were captured and enriched by Whole Exome Sequencing method (Agilent sure select v5 exome capture kit). Next Generation Sequencing (NGS) method was conducted using illumina sequencing platform to sequence the libraries with mean > 80-100X coverage. The human reference genome (GRCH37/hg19) was downloaded in order to perform the alignment to Sequence reads using BWA program [, ]. Picard and GATK version 3.6 were used to identify the relevant variants [, ]. The VEP program was used to annotate the variants . In order to perform further annotation a set of related disease databases including OMIM, HGMD, GWAS, SwissVar and Clinvar as well as published variants were used. Filtering of common variants was done according to allele frequency in ExAC, 1000 Genome phase3, dbSNP147 and EVS. Some bioinformatics online softwares such as SIFT, polyphen2, LRT, mutation assessor and mutation taster2 were also used to discover the disease causing variants.\nIn order to segregate the mutation, Sanger sequencing was conducted using ABI BigDye Terminator Cycle Sequencing Kit (Applied Biosystems®, USA) on extracted DNA (QIAamp DNA minikit, Qiagen, Germany) belonged to the patient and her family members (parents, sister and brother). Epoch Microplate Spectrophotometer (Bio Tek Instruments, USA) was utilized to calculate the quality of extracted DNA. Desired genomic region was amplified using following oligonucleotide PCR primer pairs: DPYS-E9-F: 5′-CACAAAAAGTGGGACAATCC-3′, DPYS-E9-R: 5′-GTGAAGCCTCTGACCTTGAT-3′. The obtained sequences were analyzed using Finch TV software and NCBI Blast.\nLiver biopsy specimens underwent RNA (total RNA) extraction via Invitrogen TRIzol Reagent (Thermo Fisher Scientific, USA) based on the company protocol. Quality of RNA was evaluated by Epoch Microplate Spectrophotometer (Bio Tek Instruments, USA). Normalized RNA samples were used to synthesis cDNA by Fermentas cDNA synthesis kit (Thermo Fisher Scientific, USA) per manufacturer’s instructions. In order to assess the DPYS gene expression SYBR Green Master Mix (Invitrogen) was used to perform the Real Time PCR in Rotor-Gene Q (QIAGEN, Germany) Real Time PCR cycler. The experiment was conducted in triplicate. In the current study, GAPDH (Glyceraldehyde 3-phosphate dehydrogenase) was used as an internal control gene. The following intron-spanning primer pairs were utilized in our study: DPYS-F: 5′-ACCCGACTTCCTCATGAATCT-3′, DPYS-R: 5′-CATCCGATCTTCAACACCATTCA-3′, for the gene of interest and GAPDH-F: 5′-ACAACTTTGGTATCGTGGAAGG-3′, GAPDH-R: 5′-GCCATCACGCCACAGTTTC-3′ for the reference gene (GAPDH PrimerBank ID: 378404907c2, ). Comparative threshold cycle method (2-∆∆CT) was used to compare the relative expression of DPYS gene between the patient’s liver tissue and her sister’s liver tissue who genetically confirmed to be unaffected (the liver biopsy was performed in her sister due to the increased levels of ALT, AST, Alk phosphatase and she was suspected to be affected with Autoimmune hepatitis due to a positive test for ANA and ASMA (titers ≥1:160)).", + "fulltext_subclaims": [ + "The proband was a 22-year-old Iranian woman from Fars province with DHP deficiency.", + "The proband's parents are first-degree cousins.", + "The proband had no symptoms until 20 years of age.", + "During her first pregnancy, elevated liver enzymes were detected.", + "The proband's ALT was 147 U/L.", + "The proband's AST was 108 U/L.", + "The proband's Alk-P was 350 U/L.", + "The proband had a serum iron level of 227 μg/dL.", + "The proband had a PT of 14.5 s.", + "A spontaneous abortion occurred during the first trimester of pregnancy.", + "Autoimmune antibodies were tested and the results were negative.", + "The patient was presented with bloody vomiting, diarrhea, jaundice, weight loss, and bilateral mild mid frequency sensorineural hearing loss.", + "Abdominal and pelvic ultrasonography was in favor of cirrhosis.", + "Liver biopsy confirmed cryptogenic cirrhosis.", + "The patient was initially diagnosed as having glycogen storage disease.", + "Whole-exome sequencing was conducted.", + "Elevated levels of dihydrothymine and dihydrouracil were identified in the patient’s urine.", + "Dihydrothymine in the patient’s urine was 148 μmol/mmol creatinine.", + "Dihydrothymine in controls was 1.4 ± 1.1 μmol/mmol creatinine.", + "Dihydrouracil in the patient’s urine was 254 μmol/mmol creatinine.", + "Dihydrouracil in controls was 4.9 ± 3.2 μmol/mmol creatinine.", + "There was no history of such condition in other family members.", + "All exons of protein coding regions and flanking introns were captured by Whole Exome Sequencing.", + "Next Generation Sequencing was conducted using the Illumina sequencing platform.", + "The human reference genome GRCH37/hg19 was used for alignment.", + "Variants were identified using Picard and GATK version 3.6.", + "The VEP program was used to annotate the variants.", + "Filtering of common variants was done according to allele frequency in ExAC, 1000 Genome phase3, dbSNP147, and EVS.", + "Sanger sequencing was conducted using ABI BigDye Terminator Cycle Sequencing Kit.", + "RNA was extracted from liver biopsy specimens using Invitrogen TRIzol Reagent.", + "cDNA was synthesized using Fermentas cDNA synthesis kit.", + "Real Time PCR was performed using SYBR Green Master Mix.", + "The comparative threshold cycle method (2-∆∆CT) was used to compare DPYS gene expression.", + "The patient’s sister had increased levels of ALT, AST, and Alk phosphatase.", + "The patient’s sister was suspected to be affected with Autoimmune hepatitis.", + "The patient’s sister tested positive for ANA and ASMA with titers ≥1:160." + ], + "summary": "Here, we report a 22-year-old woman with DHP deficiency. To identify the genetic cause of DHP deficiency in this patient, Whole Exome Sequencing (WES) was performed, which revealed a novel homozygote stop gain mutation (NM_001385: Exon 9, c.1501 A > T, p.K501X) in the DPYS gene. Sanger sequencing was carried out on proband and other family members in order to confirm the identified mutation. According to the homozygote genotype of the patient and heterozygote genotype of her parents, the autosomal recessive pattern of inheritance was confirmed. In addition, bioinformatics analysis of the identified variant using Mutation Taster and T-Coffee Multiple Sequence Alignment showed the pathogenicity of mutation. Moreover, mRNA expression level of DPYS gene in the proband's liver biopsy showed about 6-fold reduction compared to control, which strongly suggested the pathogenicity of the identified mutation.", + "summary_subclaims": [ + "The patient is a 22-year-old woman with DHP deficiency.", + "Whole Exome Sequencing (WES) was performed to identify the genetic cause of DHP deficiency in this patient.", + "WES revealed a novel homozygote stop gain mutation (NM_001385: Exon 9, c.1501 A > T, p.K501X) in the DPYS gene.", + "Sanger sequencing was carried out on the proband and other family members to confirm the identified mutation.", + "The patient had a homozygote genotype.", + "The parents had a heterozygote genotype.", + "The autosomal recessive pattern of inheritance was confirmed.", + "Bioinformatics analysis of the identified variant using Mutation Taster and T-Coffee Multiple Sequence Alignment showed the pathogenicity of the mutation.", + "mRNA expression level of the DPYS gene in the proband's liver biopsy showed about 6-fold reduction compared to control.", + "The 6-fold reduction in mRNA expression strongly suggested the pathogenicity of the identified mutation." + ] + }, + { + "id": "multiclinsum_test_577_en.txt", + "fulltext": "A 71-year-old man was admitted for ischemic-like chest pain occurring 10 days prior to the hospital admission. The ECG showed ST-T segment elevation without a q wave in the infero-lateral leads that could identify either myocardial infarction changes or pericarditis. A persistent release of cardiac markers was registered (troponin I 1.05 μg/l [normal value< 0.6 μg/l]) together with a slight increase in inflammatory markers and white blood cells. The clinical presentation, the ECG pattern and the laboratory data were not sufficient to rule out a diagnosis of pericarditis. Transthoracic echocardiography was not diagnostic. The patient underwent two 99mTc-tetrofosmin myocardial SPECTs on different days: the first at rest and the second after the use of nitroglycerine (0.005 mg/kg per os). The left ventricular ejection fraction (LVEF) was calculated using a previously validated and commercially available automated software (quantitative gated SPECT, QGS, Cedars-Sinai Medical Center, Los Angeles, CA ). The oral post-nitrate images clearly demonstrated an absence of uptake of 99mTc-tetrofosmin in the lateral and infero-lateral wall ; the LVEF was 31%. This absence of tracer uptake after the nitrate administration clearly indicated the presence of non-viable myocardium . The same patient underwent cardiac MRI using a clinical 1.5-T Gyroscan ACS-NT MRI scanner (Philips Medical System, Eindhoven, The Netherlands). The scan was analysed according to: a) the left ventricular function (sequences balanced-echo cine MRI) and b) the presence of scar tissue with delayed-enhancement (DE) images. Delayed sequences were obtained approximately 12 minutes after intravenous injection of 0.2 mmol/kg gadolinium diethyltriaminepentaacetic acid (Gd-DTPA) using a fast field echo sequence (slice thickness 8 mm, FOV 360 mm, flip angle 15°, TE 1.3 ms, TR 4.1 ms). Delayed enhancement images were displayed with a grey scale to optimally show normal myocardium (dark) and the region of delayed-enhancement myocardium (bright). The akinesia of the infero-apical left ventricular segment and the diskinesia of the lateral wall emerged . The LVEF was calculated as 36%; a bilateral pleural effusion was also present. The DE distribution was transmural with a dilatation of the lateral wall that appeared like an aneurysm. Necrotic myocardium usually accumulates and retains gadolinium-based contrast material for 10 or more minutes after the agent has been administered . Considering the results of myocardial SPECT and MRI together, coronary angiography was performed on the fourth day and occlusion of left circumflex coronary artery was identified. As a result of the clinical and image data, medical therapy was continued.", + "fulltext_subclaims": [ + "The patient was a 71-year-old man.", + "The patient was admitted for ischemic-like chest pain.", + "The chest pain occurred 10 days prior to hospital admission.", + "The ECG showed ST-T segment elevation without a q wave in the infero-lateral leads.", + "The ECG findings could identify either myocardial infarction changes or pericarditis.", + "A persistent release of cardiac markers was registered.", + "Troponin I was 1.05 μg/l.", + "The normal value of troponin I is < 0.6 μg/l.", + "The clinical presentation, ECG pattern, and laboratory data were not sufficient to rule out pericarditis.", + "Transthoracic echocardiography was not diagnostic.", + "The patient underwent two 99mTc-tetrofosmin myocardial SPECTs on different days.", + "The first SPECT was at rest.", + "The second SPECT was after the use of nitroglycerine (0.005 mg/kg per os).", + "The LVEF was calculated using QGS software.", + "The oral post-nitrate images demonstrated an absence of uptake of 99mTc-tetrofosmin in the lateral and infero-lateral wall.", + "The LVEF was 31%.", + "The absence of tracer uptake after nitrate administration indicated the presence of non-viable myocardium.", + "The patient underwent cardiac MRI using a 1.5-T Gyroscan ACS-NT MRI scanner.", + "The scan was analyzed for left ventricular function and the presence of scar tissue.", + "Delayed enhancement images were obtained approximately 12 minutes after intravenous injection of 0.2 mmol/kg Gd-DTPA.", + "The akinesia of the infero-apical left ventricular segment emerged.", + "The diskinesia of the lateral wall emerged.", + "The LVEF was calculated as 36%.", + "A bilateral pleural effusion was present.", + "The DE distribution was transmural with a dilatation of the lateral wall that appeared like an aneurysm.", + "Necrotic myocardium usually accumulates and retains gadolinium-based contrast material for 10 or more minutes after administration.", + "Coronary angiography was performed on the fourth day.", + "Occlusion of the left circumflex coronary artery was identified.", + "Medical therapy was continued." + ], + "summary": "We describe a case of a 71-year-old man admitted for ischemic-like chest pain in which DE-MRI and post-nitrate 99mTc-tetrofosmin myocardial scintigraphy equally contributed to the diagnosis of previous lateral myocardial infarction.", + "summary_subclaims": [ + "The patient was a 71-year-old man.", + "The patient was admitted for ischemic-like chest pain.", + "DE-MRI and post-nitrate 99mTc-tetrofosmin myocardial scintigraphy equally contributed to the diagnosis.", + "The diagnosis was previous lateral myocardial infarction." + ] + }, + { + "id": "multiclinsum_test_2681_en.txt", + "fulltext": "An 83-year-old Caucasian male was hospitalized at a local hospital for erysipelas on both legs. Upon admission, the patient was routinely tested for COVID-19 by a reverse transcriptase-polymerase chain reaction test and was found to be positive. The patient was not vaccinated against COVID-19. While in the hospital, the patient did not develop any COVID-19-related symptoms. After receiving treatment for erysipelas for seven days, the patient was stable and was discharged. While at home, COVID-19 symptoms—fever, cough, weakness, and diarrhea appeared, gradually worsened, and 13 days after the onset of symptoms, the patient was admitted to the Latvian Centre of Infectious Diseases (LCID). Upon admission to LCID, the patient did not display any neurological problems as contact with the patient could be established, and he could orient in time and space. The skin and mucous membranes were pale and dry, with signs of recurrent erysipelas on both legs. During auscultation, diffuse crackles on both sides of the lungs were found, and palpation of the abdomen did not show any pathology, including no signs of dysuria; the patient had mild peripheral edema on both legs. The patient had a febrile body temperature of 38.0 ºC, tachycardia with a heart rate of 100/min, blood pressure was 110/70 mmHg, and respiratory rate was 24/min with blood oxygen saturation of 89% on room air. The patient was diagnosed with clinically severe COVID-19 with bilateral pneumonia, as determined with radiological imaging , and respiratory failure type I .\nFrom the second to the fourth day of hospitalization, as antibacterial and symptomatic treatment was started, the patient's body temperature remained subfebrile with cough, watery stool 3–4 times a day, dyspnea, and tachypnea with low blood oxygen saturation (93%), supplemented with 4–6 L of oxygen per minute through a nasal cannula.\nOn the fifth day of hospitalization at LCID, a Clostridium difficile infection was confirmed. Patient fecal samples were collected according to the hospital's guidelines, and tests for C. difficile glutamate dehydrogenase and C. difficile toxin A/B were performed.\nFrom the sixth to the ninth day of hospitalization, the patient remained stable but required oxygen supplementation; the diarrhea had resolved by day seven.\nOn the tenth day of hospitalization, the patient presented with recurrent febrile body temperature of 38.5–39.0 ºC, severe malaise, disorientation, and blood oxygen desaturation. In addition, laboratory findings showed significantly elevated inflammatory markers, and the decision was made to switch to antibacterial therapy and to start oxygen supplementation through a high-concentration oxygen mask with a reservoir bag of 15 L per minute.\nFrom the eleventh to the fourteenth day of hospitalization, the patient's medical condition stabilized yet remained severe, showing little to no improvement. From day 15 patient's dyspnea worsened, and the blood oxygen saturation fell to 88% despite the oxygen supplementation. Oxygen supplementation was continued through a high-concentration oxygen mask with a reservoir bag of 25 L per minute, with some improvements to blood oxygen saturation (92–93%).\nGradually the patient's condition worsened with no improvements, despite the treatments. The patient died from COVID-19-associated lung damage and respiratory failure on November 2020 after being treated for 19 days. An autopsy was not performed at the request of the patient's relatives.\nThe patient had a history of cardiovascular problems (coronary heart disease, myocardial infarction, followed by percutaneous coronary intervention with stent implantation, permanent atrial fibrillation, stable angina pectoris) and a myriad of other chronic health problems, including non-Hodgkin's lymphoma, melanoma, lymphostasis in both legs after erysipelas, vitiligo, benign prostatic hyperplasia. Diffuse large B cell lymphoma was histologically diagnosed in June 2020, and since October, the patient was treated with rituximab. For the lymphoma treatment patient also took methylprednisolone 4 mg per os (p/o) once per day, allopurinole 300 mg p/o once per day, and trimethoprim-sulfamethoxazole 400–80 mg p/o twice a week. Before hospital admission, the patient was treated for his cardiovascular diseases with dabigatran 110 mg p/o twice a day, torasemide 10 mg p/o once a day, and atorvastatin 20 mg p/o once a day.\nThe patient was a non-smoker and had no history of alcohol abuse. The patient lived in a countryside house with his oldest son. The patient was retired, and no information on past employment or the patient's family history could not be obtained from the patient.\nAt LCID, the patient was treated with oxygen through a nasal cannula (4–6 L per minute) for 9 days, and a high-concentration oxygen mask with a reservoir bag (15–25 L per minute) for 10 days, dexamethasone 8 mg intravenously (i/v) once daily for 19 days, dual antibacterial therapy—ceftriaxone 2000 mg i/v once daily for 12 days and doxycycline 100 mg p/o twice a day for 11 days, then switching to piperacillin/tazobactam 4000 mg/500 mg i/v three times a day for nine days, enoxaparin-sodium 0.4 mL subcutaneously once daily for 19 days, metoprolol 50 mg p/o once daily for 19 days, torasemide 5 mg p/o once daily nine days, spironolactone 25 mg p/o once daily for 11 days, omeprazole 20 mg p/o once daily for 19 days, metamizole 1000 mg i/v in case of febrile temperature, and troxerutin 2% gel for local use for 16 days. On the day the patient died, he received methylprednisolone 1000 mg i/v and morphine 1%—3 ml i/v.The patient did not receive any antiviral drugs because he did not meet the criteria needed. The patient did not receive monoclonal antibodies or convalescent plasma because at the time the patient was hospitalized, these medications were unavailable in the country.\nThe patient's blood was tested upon admission to LCID, on the 5th, 10th, 13th, and 19th day of hospitalization. Nasopharyngeal swab, blood, urine, and fecal samples were collected from the patient on the 14th day.\nBlood test results are illustrated in Table . The parameters analyzed differed between the tests. Analysis of circulating blood cells revealed that the patient had elevated leukocyte count since day 10, reaching 14.96 × 103 cells/µL on day 19. Upon admission, the neutrophil count was normal (6.13 × 103 cells/µL, ref. range 2.0–7.0 × 103/µL) but then increased and stayed elevated since day 10. Upon admission, lymphocyte count was significantly decreased (0.23 × 103 cells/µL, ref. range 1.2–3.5 × 103/µL) falling to 0.06 on day 19. Several markers of inflammation and infection were found to be elevated. Procalcitonin levels were high upon admission, but decreased (while still being higher then normal) by day five after being treated (0.61 vs 0.24, ref. range 0.00–0.05). IL-6 was also severely elevated (93.0 pg/mL, ref. range 0.0–3.4 pg/mL). CRP levels were elevated in all of the time-points, reaching levels as high as 239.3 mg/L on the day the patient died.\nBlood plasma and peripheral blood mononuclear cells (PBMC) were isolated immediately upon receiving the peripheral blood samples. PBMCs were isolated using HISTOPAQUE by Sigma (United Kingdom) gradient. RNA was isolated from all samples obtained using the Ribospin vRD kit by GeneAll (South Korea) according to the manufacturer's instructions (adapted specifically for fecal samples). SARS-CoV-2 was detected using the Direct SARS-CoV-2 Realtime PCR kit by Vircell (Spain), and the viral load was determined using the quanty COVID-19 kit by Clonit (Italy).\nSARS CoV-2 genomic sequence was detected in all biological samples analyzed—nasopharyngeal swab, plasma, PBMCs, urine, and feces. As expected, the highest viral load was observed in the nasopharyngeal swab sample (517,000,000.0 viral copies/mL), but the viral load in feces was also notable. We believe that the detected loads illustrate an extreme case. As these patient samples were collected as a part of a larger research project, we could compare the determined viral loads with other hospitalized COVID-19 patients. The viral load of the described patient's fecal sample was significantly higher when compared to the median viral loads of the fecal samples obtained from 139 hospitalized individuals—7,224,091 vs 14,164 copies/mL (p < 0.0001), and an even more pronounced difference was observed in the case of the nasopharyngeal swab load—517,000,000 vs 5752 copies/mL (p < 0.0001) (unpublished data). Interestingly SARS-CoV-2 sequence was detectable in both cell-free blood plasma and PBMCs .\nPlasma samples were used to semi-quantitatively detect SARS-CoV-2 specific (nucleocapsid protein (NCP) and spike protein subunit 1 (S1)) IgA and IgG class antibodies using Anti-SARS-CoV-2 ELISA by Euroimmun (Germany), to quantitatively detect SARS-CoV-2 specific IgM and IgG class antibodies using Anti-SARS-CoV-2 ELISA by Antibodies-online (Germany), and to determine the levels of inflammatory cytokines using custom multiplex assay by Merck Millipore (Germany). Neither quantitative nor semi-quantitative analysis of SARS-CoV-2 antibodies detected antibody titers, indicating seronegativity.\nLevels of 14 cytokines were analyzed—granulocyte–macrophage colony-stimulating factor (GM-CSF), interferon-gamma (IFN-γ), interleukin 1β (IL-1β), interleukin 6 (IL-6), interleukin 8 (IL-8), interleukin 17A (IL-17A), interleukin 18 (IL-18), interferon gamma-induced protein 10 (IP-10), monocyte chemotactic protein 1 (MCP-1), macrophage inflammatory protein-1 alpha and beta (MIP-1α/β), platelet-derived growth factor (PDGF-AB/BB), tumor necrosis factor-alpha (TNF-α) and vascular endothelial growth factor A (VEGF-A). Levels of 5 of the analyzed cytokines—GM-CSF (< 2.6), IFN-γ (< 1.3), IL-1β (< 1.6), IL-17A (< 1.3), and MIP-1α (< 3.0), were below the detection limit of the test utilized, even though detectable and elevated levels of these cytokines could be found in a group of other hospitalized COVID-19 patients. The described patient exhibited severely elevated levels in comparison to median levels of other hospitalized patients, for example, in the case of IL-6 (20.2 vs 4.9 pg/mL), IL-18 (105.2 vs 53.6 pg/mL), and IP-10 (2007.5 vs 639.2 pg/mL), respectively. On the other hand, the level of PDGF-AB/BB was significantly lower in the patient's plasma when compared to the median levels of other hospitalized patients—1399.0 vs 25,606.0 pg/mL (unpublished data).", + "fulltext_subclaims": [ + "An 83-year-old Caucasian male was hospitalized at a local hospital for erysipelas on both legs.", + "Upon admission, the patient was routinely tested for COVID-19 by a reverse transcriptase-polymerase chain reaction test and was found to be positive.", + "The patient was not vaccinated against COVID-19.", + "While in the hospital, the patient did not develop any COVID-19-related symptoms.", + "After receiving treatment for erysipelas for seven days, the patient was stable and was discharged.", + "While at home, COVID-19 symptoms—fever, cough, weakness, and diarrhea—appeared.", + "The symptoms gradually worsened.", + "Thirteen days after the onset of symptoms, the patient was admitted to the Latvian Centre of Infectious Diseases (LCID).", + "Upon admission to LCID, the patient did not display any neurological problems.", + "The skin and mucous membranes were pale and dry, with signs of recurrent erysipelas on both legs.", + "During auscultation, diffuse crackles on both sides of the lungs were found.", + "The patient had a febrile body temperature of 38.0 ºC.", + "The patient had tachycardia with a heart rate of 100/min.", + "Blood pressure was 110/70 mmHg.", + "Respiratory rate was 24/min with blood oxygen saturation of 89% on room air.", + "The patient was diagnosed with clinically severe COVID-19 with bilateral pneumonia, as determined with radiological imaging.", + "The patient was diagnosed with respiratory failure type I.", + "From the second to the fourth day of hospitalization, the patient's body temperature remained subfebrile.", + "The patient had cough, watery stool 3–4 times a day, dyspnea, and tachypnea.", + "The patient had low blood oxygen saturation (93%), supplemented with 4–6 L of oxygen per minute through a nasal cannula.", + "On the fifth day of hospitalization at LCID, a Clostridium difficile infection was confirmed.", + "Patient fecal samples were collected according to the hospital's guidelines.", + "Tests for C. difficile glutamate dehydrogenase and C. difficile toxin A/B were performed.", + "From the sixth to the ninth day of hospitalization, the patient remained stable but required oxygen supplementation.", + "The diarrhea had resolved by day seven.", + "On the tenth day of hospitalization, the patient presented with recurrent febrile body temperature of 38.5–39.0 ºC.", + "The patient had severe malaise and disorientation.", + "The patient had blood oxygen desaturation.", + "Laboratory findings showed significantly elevated inflammatory markers.", + "The decision was made to switch to antibacterial therapy.", + "Oxygen supplementation was started through a high-concentration oxygen mask with a reservoir bag of 15 L per minute.", + "From the eleventh to the fourteenth day of hospitalization, the patient's medical condition stabilized yet remained severe.", + "The patient showed little to no improvement.", + "From day 15, the patient's dyspnea worsened.", + "The patient's blood oxygen saturation fell to 88% despite oxygen supplementation.", + "Oxygen supplementation was continued through a high-concentration oxygen mask with a reservoir bag of 25 L per minute.", + "The patient's condition gradually worsened with no improvements, despite the treatments.", + "The patient died from COVID-19-associated lung damage and respiratory failure on November 2020 after being treated for 19 days.", + "An autopsy was not performed at the request of the patient's relatives.", + "The patient had a history of cardiovascular problems, including coronary heart disease, myocardial infarction, and permanent atrial fibrillation.", + "The patient had a history of non-Hodgkin's lymphoma.", + "Diffuse large B cell lymphoma was histologically diagnosed in June 2020.", + "Since October, the patient was treated with rituximab.", + "The patient took methylprednisolone 4 mg per os once per day.", + "The patient took allopurinole 300 mg per os once per day.", + "The patient took trimethoprim-sulfamethoxazole 400–80 mg per os twice a week.", + "Before hospital admission, the patient was treated with dabigatran 110 mg per os twice a day.", + "Before hospital admission, the patient was treated with torasemide 10 mg per os once a day.", + "Before hospital admission, the patient was treated with atorvastatin 20 mg per os once a day.", + "The patient was a non-smoker.", + "The patient had no history of alcohol abuse.", + "The patient lived in a countryside house with his oldest son.", + "The patient was retired.", + "No information on past employment or the patient's family history could be obtained from the patient.", + "At LCID, the patient was treated with oxygen through a nasal cannula (4–6 L per minute) for 9 days.", + "At LCID, the patient was treated with a high-concentration oxygen mask with a reservoir bag (15–25 L per minute) for 10 days.", + "The patient received dexamethasone 8 mg intravenously once daily for 19 days.", + "The patient received dual antibacterial therapy—ceftriaxone 2000 mg intravenously once daily for 12 days and doxycycline 100 mg per os twice a day for 11 days.", + "The patient received piperacillin/tazobactam 4000 mg/500 mg intravenously three times a day for nine days.", + "The patient received enoxaparin-sodium 0.4 mL subcutaneously once daily for 19 days.", + "The patient received metoprolol 50 mg per os once daily for 19 days.", + "The patient received torasemide 5 mg per os once daily for nine days.", + "The patient received spironolactone 25 mg per os once daily for 11 days.", + "The patient received omeprazole 20 mg per os once daily for 19 days.", + "The patient received metamizole 1000 mg intravenously in case of febrile temperature.", + "The patient received troxerutin 2% gel for local use for 16 days.", + "On the day the patient died, he received methylprednisolone 1000 mg intravenously.", + "On the day the patient died, he received morphine 1%—3 ml intravenously.", + "The patient did not receive any antiviral drugs because he did not meet the criteria needed.", + "The patient did not receive monoclonal antibodies or convalescent plasma because these medications were unavailable in the country at the time.", + "The patient's blood was tested upon admission to LCID, on the 5th, 10th, 13th, and 19th day of hospitalization.", + "Nasopharyngeal swab, blood, urine, and fecal samples were collected from the patient on the 14th day.", + "SARS-CoV-2 genomic sequence was detected in all biological samples analyzed—nasopharyngeal swab, plasma, PBMCs, urine, and feces.", + "The highest viral load was observed in the nasopharyngeal swab sample (517,000,000.0 viral copies/mL).", + "The viral load in feces was also notable.", + "The patient's fecal sample had a viral load of 7,224,091 copies/mL.", + "The patient's nasopharyngeal swab had a viral load of 517,000,000 copies/mL.", + "SARS-CoV-2 sequence was detectable in both cell-free blood plasma and PBMCs.", + "Neither quantitative nor semi-quantitative analysis of SARS-CoV-2 antibodies detected antibody titers, indicating seronegativity.", + "Levels of 5 of the analyzed cytokines—GM-CSF, IFN-γ, IL-1β, IL-17A, and MIP-1α—were below the detection limit of the test utilized.", + "The described patient exhibited severely elevated levels of IL-6, IL-18, and IP-10 in comparison to median levels of other hospitalized patients." + ], + "summary": "Here we describe a fatal COVID-19 case of an 83-year-old Caucasian male patient with various underlying comorbidities, including cardiovascular and autoimmune disorders, as well as immunosuppression due to lymphoma treatment. Upon admission, the patient was radiologically diagnosed with severe COVID-19. The patient was febrile and presented with diarrhea, continued dyspnea, tachypnea, and low blood oxygen saturation, treated with high-concentration oxygen supplementation and antibacterial therapy. Overall the patient was treated for COVID-19 for 19 days. Blood tests were performed upon admission, on the fifth, 10th, 13th, and 19th day. In addition, nasopharyngeal swab, blood, urine, and fecal samples were collected from the patient on the 14th day for virological and immunological investigations. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detectable in all samples collected from this patient, including blood plasma and peripheral blood mononuclear cells (PBMC), with very high viral loads. However, neither virus-specific IgA, IgM, nor IgG antibodies were detectable.", + "summary_subclaims": [ + "The patient was an 83-year-old Caucasian male.", + "The patient had various underlying comorbidities.", + "The patient had cardiovascular disorders.", + "The patient had autoimmune disorders.", + "The patient had immunosuppression due to lymphoma treatment.", + "The patient was radiologically diagnosed with severe COVID-19.", + "The patient was febrile.", + "The patient presented with diarrhea.", + "The patient presented with continued dyspnea.", + "The patient presented with tachypnea.", + "The patient had low blood oxygen saturation.", + "The patient was treated with high-concentration oxygen supplementation.", + "The patient was treated with antibacterial therapy.", + "The patient was treated for COVID-19 for 19 days.", + "Blood tests were performed upon admission.", + "Blood tests were performed on the fifth day.", + "Blood tests were performed on the 10th day.", + "Blood tests were performed on the 13th day.", + "Blood tests were performed on the 19th day.", + "Nasopharyngeal swab samples were collected on the 14th day.", + "Blood samples were collected on the 14th day.", + "Urine samples were collected on the 14th day.", + "Fecal samples were collected on the 14th day.", + "SARS-CoV-2 was detectable in all samples collected from the patient.", + "SARS-CoV-2 was detectable in blood plasma.", + "SARS-CoV-2 was detectable in peripheral blood mononuclear cells.", + "SARS-CoV-2 had very high viral loads.", + "Virus-specific IgA antibodies were not detectable.", + "Virus-specific IgM antibodies were not detectable.", + "Virus-specific IgG antibodies were not detectable." + ] + }, + { + "id": "multiclinsum_test_2936_en.txt", + "fulltext": "A 68-year-old man was referred to Kindai University in 2004 with bilateral uveitis of unknown cause. The right eye had lost vision due to suspected Candida keratitis after penetrating keratoplasty, which was performed in 2007. A mild anterior chamber inflammation and keratic precipitates with small corneal oedema, followed by refractory secondary glaucoma, caused bullous keratopathy in the left eye that necessitated DSAEK in 2011. The clinical findings observed during these periods, such as unilateral high intraocular pressure and corneal oedema with keratic precipitates, were suggestive of cytomegalovirus (CMV) corneal endotheliitis. A diagnosis of CMV corneal endotheliitis was made based on detection of CMV DNA in the aqueous humour after DSAEK. Corneal grafting failed even with administration of 0.5% ganciclovir eye drop six times with 0.1% fluorometholone eye drop four times daily for more than a year. After the second DSAEK in 2013, 1.0% voriconazole, 0.5% ganciclovir, and 0.1% betamethasone phosphate eye drops continued to be administered four times daily for 2 years. In 2015, the patient presented with small crystalline opacities in the centre of the cornea that progressed extremely slowly and had multiplied by 2017 . The patient complained visual disturbance without any eye pain or foreign body sensation when the corneal opacity covered the visual axis, although he did not exhibit any subjective symptoms when the keratitis occurred for the first time. Gram staining of the scraped cornea revealed an unstained small oval microorganism that was only visible by Fungiflora Y staining . Given the past episode of vision loss of the other eye due to suspected Candida keratitis, we administered two doses of voriconazole by intrastromal injection. Since the treatment was ineffective, penetrating keratoplasty was performed. The excised corneal tissue was fixed with formalin, embedded in paraffin, and processed for histological analysis.\nHistologically, numerous oval organisms, 1.3–2.6 μm in diameter, were found throughout the corneal stroma. The organisms could be identified by haematoxylin and eosin staining and Ziehl–Neelsen staining, and fluoresced under ultraviolet illumination by Fungiflora Y and Uvitex 2B staining, but were unstained with periodic acid-Schiff reaction and Grocott’s staining . For TEM observation, ultrathin sections were prepared from the targeted area of paraffin sections after osmification and embedding in Epon blocks by the inverted beam capsule method . They were observed with an HT 7700 microscope (Hitachi High-Technologies, Tokyo, Japan). A polar tube with multiple loose coils—which is consistent with the morphology of microsporidia—was detected in the spore-like elements of the microorganisms by TEM . The corneal graft remains transparent and no clinical findings suggestive of recurrence of microsporidial keratitis nor graft rejection is found with administration of 0.1% betamethasone phosphate eye drop four times daily at 1 year and half postoperatively.", + "fulltext_subclaims": [ + "A 68-year-old man was referred to Kindai University in 2004 with bilateral uveitis of unknown cause.", + "The right eye had lost vision due to suspected Candida keratitis after penetrating keratoplasty, which was performed in 2007.", + "A mild anterior chamber inflammation and keratic precipitates with small corneal oedema, followed by refractory secondary glaucoma, caused bullous keratopathy in the left eye that necessitated DSAEK in 2011.", + "The clinical findings observed during these periods, such as unilateral high intraocular pressure and corneal oedema with keratic precipitates, were suggestive of cytomegalovirus (CMV) corneal endotheliitis.", + "A diagnosis of CMV corneal endotheliitis was made based on detection of CMV DNA in the aqueous humour after DSAEK.", + "Corneal grafting failed even with administration of 0.5% ganciclovir eye drop six times with 0.1% fluorometholone eye drop four times daily for more than a year.", + "After the second DSAEK in 2013, 1.0% voriconazole, 0.5% ganciclovir, and 0.1% betamethasone phosphate eye drops continued to be administered four times daily for 2 years.", + "In 2015, the patient presented with small crystalline opacities in the centre of the cornea that progressed extremely slowly and had multiplied by 2017.", + "The patient complained visual disturbance without any eye pain or foreign body sensation when the corneal opacity covered the visual axis.", + "Gram staining of the scraped cornea revealed an unstained small oval microorganism that was only visible by Fungiflora Y staining.", + "Given the past episode of vision loss of the other eye due to suspected Candida keratitis, we administered two doses of voriconazole by intrastromal injection.", + "Since the treatment was ineffective, penetrating keratoplasty was performed.", + "The excised corneal tissue was fixed with formalin, embedded in paraffin, and processed for histological analysis.", + "Histologically, numerous oval organisms, 1.3–2.6 μm in diameter, were found throughout the corneal stroma.", + "The organisms could be identified by haematoxylin and eosin staining and Ziehl–Neelsen staining.", + "The organisms fluoresced under ultraviolet illumination by Fungiflora Y and Uvitex 2B staining.", + "The organisms were unstained with periodic acid-Schiff reaction and Grocott’s staining.", + "For TEM observation, ultrathin sections were prepared from the targeted area of paraffin sections after osmification and embedding in Epon blocks by the inverted beam capsule method.", + "They were observed with an HT 7700 microscope (Hitachi High-Technologies, Tokyo, Japan).", + "A polar tube with multiple loose coils—which is consistent with the morphology of microsporidia—was detected in the spore-like elements of the microorganisms by TEM.", + "The corneal graft remains transparent and no clinical findings suggestive of recurrence of microsporidial keratitis nor graft rejection is found with administration of 0.1% betamethasone phosphate eye drop four times daily at 1 year and half postoperatively." + ], + "summary": "A 68-year-old man presented with multiple crystalline opacities in the corneal stroma that progressed extremely slowly after DSAEK. Fungiflora Y staining of corneal scrapings from the affected regions revealed an oval microorganism. Topical voriconazole administration was ineffective and penetrating keratoplasty was performed. Histological and molecular analyses were carried out on the excised cornea. Ziehl-Neelsen staining revealed an acid-fast, oval organism that was visible by ultraviolet illumination after Fungiflora Y and Uvitex 2B staining, whereas periodic acid-Schiff and Grocott's staining did not yield any significant findings. Microsporidium was detected by TEM of FFPE tissue. Nosema or Vittaforma sp. was suspected as the causative microorganism by PCR of FFPE tissue and by the fact that those species are known to cause eye infection. The corneal graft has maintained transparency at 1 year and half postoperatively.", + "summary_subclaims": [ + "The patient was a 68-year-old man.", + "The patient had multiple crystalline opacities in the corneal stroma.", + "The opacities progressed extremely slowly after DSAEK.", + "Fungiflora Y staining of corneal scrapings revealed an oval microorganism.", + "Topical voriconazole administration was ineffective.", + "Penetrating keratoplasty was performed.", + "Histological and molecular analyses were carried out on the excised cornea.", + "Ziehl-Neelsen staining revealed an acid-fast, oval organism.", + "The organism was visible by ultraviolet illumination after Fungiflora Y and Uvitex 2B staining.", + "Periodic acid-Schiff and Grocott's staining did not yield any significant findings.", + "Microsporidium was detected by TEM of FFPE tissue.", + "Nosema or Vittaforma sp. was suspected as the causative microorganism by PCR of FFPE tissue.", + "Nosema or Vittaforma sp. was suspected as the causative microorganism by the fact that those species are known to cause eye infection.", + "The corneal graft has maintained transparency at 1 year and half postoperatively." + ] + }, + { + "id": "multiclinsum_test_2013_en.txt", + "fulltext": "A 1-month-old infant (sex, female; height, 51.2 cm; body weight, 3.1 kg; body surface area, 0.21 m2) was hospitalized due to IAA/VSD/PDA/PH .\nCardiovascular CT revealed a ventricular septal defect of 13 mm and the continuity of the aortic arch at the distal end of the left subclavian artery was interrupted, where the descending aorta was connected to the left pulmonary artery via an arterial catheter with an internal diameter of about 5 mm. Meantime, the ratio of pulmonary to systemic blood pressure measured by cardiac ultrasound was 0.95, which met the diagnostic criteria of congenital heart disease combined with severe pulmonary hypertension.\nAfter completing relevant examinations, aortic arch interruption correction, ventricular septal defect repair, ductus arteriosus cut-off, and suture were performed and the operation was successful. Due to obvious myocardial oedema in the infant, sternal closure was delayed. The left atrial and right ventricular pressure monitoring tubes, both of which were connected through a triplet, were inserted into right pulmonary vein and pulmonary artery, respectively, and the triplet was in closed condition ( and ). When the infant returned to intensive care unit, ventilator-assisted breathing was received, and the non-invasive cardiac monitoring system (Most-Care system) was used to closely monitor the vital signs. Meanwhile, the left atrial and right ventricular pressure measuring tubes were separately connected to the monitor through the pressure measuring kits to dynamically monitor the changes of the left atrial and right ventricular pressure . According to the infant’s condition, selective pumping of vasoactive drugs such as dopamine, dobutamine, milrinone, epinephrine, and other vasoactive drugs were given to improve coronary perfusion and cardiac function.\nOn the night of the surgery, pulmonary hypertensive crisis was triggered by endotracheal intubation with sputum aspiration. Pulmonary artery pressure soared from 18–22/13–15 mmHg to 80/53 mmHg, systemic circulation pressure plunged from 78–83/44–49 mmHg to 40/22 mmHg, blood oxygen saturation (SpO2) decreased from 98% to 84%, and heart rate dropped from 150–158 b.p.m. to 51 b.p.m. simultaneously . Emergency bedside thoracotomy was given, by which it is found that the right atrium and right ventricle were significantly enlarged with distress, and the triplet was turned on urgently to make the left atrial and right ventricular pressure monitoring tubes connected. Meantime, pure oxygen and nitric oxide (20 ppm) were inhaled by breathing bag, and fentanyl, midazolam, rocuronium bromide, and other drugs were given to enhance sedation and muscle relaxation therapy. The systemic blood pressure increased instantly to 68–72/44–50 mmHg, right cardiac distress relieved immediately, and the heart rate soon increased to 83–110 b.p.m. Three minutes later, the SpO2 increased to 89%, and the pulmonary artery pressure decreased to 19–22/15–17 mmHg. The triplet was turned off, and ventilator was given to assist breathing subsequently, and then the SpO2 increased to 95–99%, blood pressure to 83–88/50–53 mmHg, and heart rate to 155–161 b.p.m. . After 20 min of observation, the infant’s vital signs were stable and there was no recurrence of pulmonary hypertensive crisis, so the infant was given delayed sternal closure again.\nThirty-six hours after surgery, bedside sternal closure was performed, the left atrial and right ventricular pressure monitoring tubes were removed smoothly, and the infant was discharged 9 days later. One year after surgery, transthoracic echocardiography showed the infant recovered well .", + "fulltext_subclaims": [ + "The infant was 1 month old.", + "The infant was female.", + "The infant's body weight was 3.1 kg.", + "The infant was hospitalized due to IAA/VSD/PDA/PH.", + "Cardiovascular CT revealed a ventricular septal defect of 13 mm.", + "The continuity of the aortic arch at the distal end of the left subclavian artery was interrupted.", + "The descending aorta was connected to the left pulmonary artery via an arterial catheter with an internal diameter of about 5 mm.", + "The ratio of pulmonary to systemic blood pressure measured by cardiac ultrasound was 0.95.", + "The diagnostic criteria of congenital heart disease combined with severe pulmonary hypertension were met.", + "Aortic arch interruption correction was performed.", + "Ventricular septal defect repair was performed.", + "Ductus arteriosus cut-off and suture were performed.", + "The operation was successful.", + "Sternal closure was delayed due to obvious myocardial oedema.", + "Left atrial and right ventricular pressure monitoring tubes were inserted into right pulmonary vein and pulmonary artery, respectively.", + "The triplet was in closed condition.", + "The infant received ventilator-assisted breathing after returning to the intensive care unit.", + "The Most-Care system was used to closely monitor vital signs.", + "The left atrial and right ventricular pressure measuring tubes were separately connected to the monitor through the pressure measuring kits.", + "Selective pumping of vasoactive drugs such as dopamine, dobutamine, milrinone, epinephrine, and other vasoactive drugs were given.", + "Pulmonary hypertensive crisis was triggered by endotracheal intubation with sputum aspiration.", + "Pulmonary artery pressure soared from 18–22/13–15 mmHg to 80/53 mmHg.", + "Systemic circulation pressure plunged from 78–83/44–49 mmHg to 40/22 mmHg.", + "Blood oxygen saturation decreased from 98% to 84%.", + "Heart rate dropped from 150–158 b.p.m. to 51 b.p.m.", + "Emergency bedside thoracotomy was given.", + "The right atrium and right ventricle were significantly enlarged with distress.", + "The triplet was turned on urgently.", + "Pure oxygen and nitric oxide (20 ppm) were inhaled by breathing bag.", + "Fentanyl, midazolam, rocuronium bromide, and other drugs were given.", + "Systemic blood pressure increased to 68–72/44–50 mmHg.", + "Right cardiac distress relieved immediately.", + "Heart rate increased to 83–110 b.p.m.", + "Three minutes later, SpO2 increased to 89%.", + "Pulmonary artery pressure decreased to 19–22/15–17 mmHg.", + "The triplet was turned off.", + "Ventilator was given to assist breathing.", + "SpO2 increased to 95–99%.", + "Blood pressure increased to 83–88/50–53 mmHg.", + "Heart rate increased to 155–161 b.p.m.", + "After 20 min of observation, the infant’s vital signs were stable.", + "There was no recurrence of pulmonary hypertensive crisis.", + "Delayed sternal closure was given again.", + "Thirty-six hours after surgery, bedside sternal closure was performed.", + "The left atrial and right ventricular pressure monitoring tubes were removed smoothly.", + "The infant was discharged 9 days later.", + "One year after surgery, transthoracic echocardiography showed the infant recovered well." + ], + "summary": "An infant with congenital heart disease had undergone cardiac surgery successfully. Due to obvious myocardial oedema, sternal closure was delayed. The left atrial and right ventricular pressure monitoring tubes, both of which were connected through a triplet, were inserted into right pulmonary vein and pulmonary artery, respectively, and the triplet was in closed condition. On the night of the surgery, pulmonary hypertensive crisis occurred. Emergency bedside thoracotomy was given, and the triplet was turned on urgently to make the left atrial and right ventricular pressure monitoring tubes connected. Meantime, conventional treatment was performed. Eventually, the pulmonary hypertensive crisis was quickly relieved, and the infant was discharged 9 days later.", + "summary_subclaims": [ + "An infant with congenital heart disease had undergone cardiac surgery successfully.", + "Sternal closure was delayed due to obvious myocardial oedema.", + "The left atrial and right ventricular pressure monitoring tubes were connected through a triplet.", + "The triplet was in closed condition.", + "On the night of the surgery, pulmonary hypertensive crisis occurred.", + "Emergency bedside thoracotomy was given.", + "The triplet was turned on urgently to make the left atrial and right ventricular pressure monitoring tubes connected.", + "Conventional treatment was performed.", + "The pulmonary hypertensive crisis was quickly relieved.", + "The infant was discharged 9 days later." + ] + }, + { + "id": "multiclinsum_test_2212_en.txt", + "fulltext": "A 24-year-old woman was referred to the ENT service with the presentation of a painless mass in the right supraclavicular region from 2 years ago. The mass had increased in size over that time. The patient had no history of trauma, surgery, inflammation, fever, nocturnal sweating, weight loss, dysphagia, shortness of breath, or hoarseness. Furthermore, there was no history of cutaneous neoplasms, visceral malignancies, or family members with similar presentation. In her past medical history, she had multiple sclerosis and is being treated with rituximab.\nA physical examination revealed a 3×4 cm firm, semi-mobile, semi-compressible, none tender, round mass in the right supraclavicular region. The skin over the swelling was normal and non-adherent to the underlying mass.\nThere was no abnormal pulsation or bruit. Moreover, no cervical lymphadenopathy was appreciated. The CT scan of the neck with contrast revealed a heterogeneous solid mass measuring 40×25×20 mm infiltrated the most distal part of the right sternocleidomastoid muscle in the base of the neck containing mottled hyperemic foci. The CT scan report was compatible with mesenchymal sarcoma . FNAC showed benign-looking follicular cells. Then ultrasonography of the neck was performed, with a normal thyroid on both sides. A heterogeneous focus contained multiple tubular, tortuous foci and low flow without connection to the right thyroid in the inferior-lateral region of the sternocleidomastoid muscle insertion on the right. The first diagnosis was vascular malformation. Doubting the FNA's answer, the FNA repeated, which was bloody. According to the findings, the decision was made to perform surgery. The surgical dissection showed a thrombosed vascular mass of the supraclavicular region originating in the sternocleidomastoid muscle .\nThe pedicle of the mass in the muscle was ligated, and the swelling was excised completely. Furthermore, there was no recurrence of the tumor at the 6-month follow-up. Histopathological examination confirmed the diagnosis of cavernous hemangioma.\nA macroscopic inspection of the surgically excised specimen showed a well-defined mass lesion 4.3 × 3.2 × 2.5 cm, revealing a brownish-red solid cut surface with a soft consistency. Microscopic inspection showed a benign vascular lesion featuring cavernous hemangioma composed of large dilated vascular channels lined by flat endothelium .", + "fulltext_subclaims": [ + "The patient is a 24-year-old woman.", + "She was referred to the ENT service.", + "She presented with a painless mass in the right supraclavicular region.", + "The mass had been present for 2 years.", + "The mass had increased in size over that time.", + "The patient had no history of trauma.", + "The patient had no history of surgery.", + "The patient had no history of inflammation.", + "The patient had no history of fever.", + "The patient had no history of nocturnal sweating.", + "The patient had no history of weight loss.", + "The patient had no history of dysphagia.", + "The patient had no history of shortness of breath.", + "The patient had no history of hoarseness.", + "There was no history of cutaneous neoplasms.", + "There was no history of visceral malignancies.", + "There was no family history of similar presentation.", + "In her past medical history, she had multiple sclerosis.", + "She is being treated with rituximab.", + "A physical examination revealed a 3×4 cm firm, semi-mobile, semi-compressible, none tender, round mass in the right supraclavicular region.", + "The skin over the swelling was normal.", + "The skin was non-adherent to the underlying mass.", + "There was no abnormal pulsation.", + "There was no bruit.", + "No cervical lymphadenopathy was appreciated.", + "The CT scan of the neck with contrast revealed a heterogeneous solid mass measuring 40×25×20 mm.", + "The mass infiltrated the most distal part of the right sternocleidomastoid muscle in the base of the neck.", + "The CT scan showed mottled hyperemic foci.", + "The CT scan report was compatible with mesenchymal sarcoma.", + "FNAC showed benign-looking follicular cells.", + "Ultrasonography of the neck was performed.", + "The ultrasonography showed a normal thyroid on both sides.", + "A heterogeneous focus contained multiple tubular, tortuous foci and low flow without connection to the right thyroid.", + "The heterogeneous focus was in the inferior-lateral region of the sternocleidomastoid muscle insertion on the right.", + "The first diagnosis was vascular malformation.", + "The FNA was repeated.", + "The repeated FNA was bloody.", + "The decision was made to perform surgery.", + "The surgical dissection showed a thrombosed vascular mass of the supraclavicular region.", + "The mass originated in the sternocleidomastoid muscle.", + "The pedicle of the mass in the muscle was ligated.", + "The swelling was excised completely.", + "There was no recurrence of the tumor at the 6-month follow-up.", + "Histopathological examination confirmed the diagnosis of cavernous hemangioma.", + "A macroscopic inspection showed a well-defined mass lesion 4.3 × 3.2 × 2.5 cm.", + "The mass revealed a brownish-red solid cut surface with a soft consistency.", + "Microscopic inspection showed a benign vascular lesion.", + "The lesion was composed of large dilated vascular channels lined by flat endothelium." + ], + "summary": "The present case was a 24-year-old woman with intramuscular hemangioma of the sternocleidomastoid muscle, manifesting a mass in the right supraclavicular region involving the sternocleidomastoid muscle. The woman was treated with surgery and achieved complete treatment. After surgery, the patient was kept under regular follow-up for the last six months without any evidence of recurrence.", + "summary_subclaims": [ + "The patient was a 24-year-old woman.", + "The patient had intramuscular hemangioma of the sternocleidomastoid muscle.", + "The mass was in the right supraclavicular region.", + "The mass involved the sternocleidomastoid muscle.", + "The woman was treated with surgery.", + "The patient achieved complete treatment.", + "The patient was kept under regular follow-up for the last six months.", + "There was no evidence of recurrence." + ] + }, + { + "id": "multiclinsum_test_1274_en.txt", + "fulltext": "A 43-year-old Caucasian man on anti-retroviral therapy (lopinavir/ritonavi and emtricitabine/tenofovir) for HIV/AIDS presented in September 2008 with a three-month history of low grade fevers, night sweats, generalized fatigue, lethargy, unintentional weight loss, and bilateral lower extremity swelling. He had a CD4 count of 196 cells/mm3, and a viral load of <50 copies/mL. He had been diagnosed with HIV-infection in 1990; his CD4 nadir was 4 (0.6%) in February 2004 with high viremia, 175,671 copies/mL. After initiation of potent anti-retroviral therapy the HIV viral load has been undetectable since October 2004.\nA physical exam of our patient revealed diffuse lymphadenopathy in his cervical, axillary and inguinal areas, splenomegaly, and pitting edema in both lower extremities. Computed tomography of his chest, abdomen and pelvis demonstrated widespread mediastinal, hilar, axillary, retro-peritoneal and pelvic lymphadenopathy, as well as the splenomegaly. A laboratory workup revealed a hemoglobin level of 8.5 mg/dL, a white blood cell count (WBC) of 4,600 cells/μL, an albumin level of 2.5 mg/dL, and a Westergren sedimentation rate of 90 mm/hr. A lower extremity Doppler was negative for deep venous thrombosis.\nHistological examination of lymph node biopsy material revealed marked plasma cell infiltration, and follicles that were variable in appearance, from marked follicular hyperplasia to involution and dendritic cell hyperplasia . Immunohistochemical studies demonstrated HHV-8 positive , and plasmablastic foci associated with an intense polytypic plasma cell infiltrate. These findings were consistent with the diagnosis of MCD--plasma cell variant. Our patient was discharged from the hospital and was scheduled to start treatment for MCD.\nThree weeks later our patient presented with lower abdominal pain, urinary retention, and lower extremity weakness. Neurological examination revealed bilaterally reduced motor power (4/5) in all major muscle groups in his lower extremities, along with a positive Babinski sign on the right. Deep tendon reflexes were normal bilaterally. An ultrasound of his pelvis demonstrated bladder distention. A Foley catheter was inserted and 2 liters of urine was evacuated, with complete relief of pain.\nA Gadolinium magnetic resonance imaging (MRI) of his spine was done to rule out spinal cord compression; it revealed abnormal spinal cord signal intensity involving several cervical and thoracic segments, associated with expansion of the cord and mild enhancement of the areas of abnormal T2 signal . MRI of the brain revealed a few patchy areas of abnormal T2 signal in the peri-ventricular and pontine white matter.\nA lumbar puncture was performed: cerebrospinal fluid (CSF) contained an elevated WBC of 50 cells/mm3, with 90% lymphocytes, and a high protein level of 243 mg/dL; cytological analysis identified mature reactive lymphocytes with no evidence of lymphoma on flow cytometry. Polymerase chain reaction (PCR) was positive for EBV DNA in the CSF, but negative for HHV-8, cytomegalovirus (CMV), herpes simplex virus (HSV) and Varicella-Zoster virus (VZV). Treatment with high-dose dexamethasone was initiated. Our patient was then transferred to the National Institute of Health (NIH) and started on a treatment protocol of high-dose zidovudine (AZT) and valganciclovir for MCD (ClinicalTrials.gov identifier: NCT00099073). Subsequent laboratory follow-up revealed marked improvement over the first seven days of treatment, including a marked decrease in WBC and protein in his CSF. A follow-up MRI demonstrated resolution of all spinal cord lesions. He is now doing well, his last CD4 was 322 (15%), viral load < 50 copies/mL in August 2010.", + "fulltext_subclaims": [ + "The patient is a 43-year-old Caucasian man.", + "He is on anti-retroviral therapy (lopinavir/ritonavir and emtricitabine/tenofovir) for HIV/AIDS.", + "He presented in September 2008 with a three-month history of low grade fevers.", + "He had a CD4 count of 196 cells/mm3.", + "He had a viral load of <50 copies/mL.", + "He had been diagnosed with HIV-infection in 1990.", + "His CD4 nadir was 4 (0.6%) in February 2004.", + "After initiation of potent anti-retroviral therapy the HIV viral load has been undetectable since October 2004.", + "A physical exam revealed diffuse lymphadenopathy in his cervical, axillary and inguinal areas.", + "Computed tomography of his chest, abdomen and pelvis demonstrated widespread mediastinal, hilar, axillary, retro-peritoneal and pelvic lymphadenopathy.", + "A laboratory workup revealed a hemoglobin level of 8.5 mg/dL.", + "A lower extremity Doppler was negative for deep venous thrombosis.", + "Histological examination of lymph node biopsy material revealed marked plasma cell infiltration.", + "Immunohistochemical studies demonstrated HHV-8 positive.", + "These findings were consistent with the diagnosis of MCD--plasma cell variant.", + "Our patient was discharged from the hospital and was scheduled to start treatment for MCD.", + "Three weeks later our patient presented with lower abdominal pain.", + "Neurological examination revealed bilaterally reduced motor power (4/5) in all major muscle groups in his lower extremities.", + "An ultrasound of his pelvis demonstrated bladder distention.", + "A Foley catheter was inserted and 2 liters of urine was evacuated.", + "A Gadolinium magnetic resonance imaging (MRI) of his spine was done to rule out spinal cord compression.", + "MRI of the brain revealed a few patchy areas of abnormal T2 signal in the peri-ventricular and pontine white matter.", + "A lumbar puncture was performed.", + "Cerebrospinal fluid (CSF) contained an elevated WBC of 50 cells/mm3, with 90% lymphocytes.", + "Polymerase chain reaction (PCR) was positive for EBV DNA in the CSF.", + "Treatment with high-dose dexamethasone was initiated.", + "Our patient was then transferred to the National Institute of Health (NIH) and started on a treatment protocol of high-dose zidovudine (AZT) and valganciclovir for MCD.", + "Subsequent laboratory follow-up revealed marked improvement over the first seven days of treatment.", + "A follow-up MRI demonstrated resolution of all spinal cord lesions.", + "He is now doing well.", + "His last CD4 was 322 (15%).", + "His viral load was < 50 copies/mL in August 2010." + ], + "summary": "We describe the case of a 43-year-old Caucasian man with acquired immune deficiency syndrome who presented with fever, weight loss and diffuse lymphadenopathy, and was diagnosed with multi-centric Castleman's disease. He presented three weeks later with lower extremity weakness and urinary retention, at which time cerebrospinal fluid contained lymphocytic pleocytosis and elevated protein. Magnetic resonance imaging demonstrated abnormal spinal cord signal intensity over several cervical and thoracic segments, suggesting the diagnosis of myelitis. Our patient was ultimately diagnosed with Epstein-Barr virus myelitis, as Epstein-Barr virus DNA was detected by polymerase chain reaction in the cerebrospinal fluid.", + "summary_subclaims": [ + "The patient was a 43-year-old Caucasian man.", + "The patient had acquired immune deficiency syndrome.", + "The patient presented with fever, weight loss, and diffuse lymphadenopathy.", + "The patient was diagnosed with multi-centric Castleman's disease.", + "The patient presented three weeks later with lower extremity weakness and urinary retention.", + "Cerebrospinal fluid contained lymphocytic pleocytosis.", + "Cerebrospinal fluid had elevated protein.", + "Magnetic resonance imaging demonstrated abnormal spinal cord signal intensity over several cervical and thoracic segments.", + "The imaging findings suggested the diagnosis of myelitis.", + "The patient was ultimately diagnosed with Epstein-Barr virus myelitis.", + "Epstein-Barr virus DNA was detected by polymerase chain reaction in the cerebrospinal fluid." + ] + }, + { + "id": "multiclinsum_test_2296_en.txt", + "fulltext": "A 15-year-old previously healthy male presented with a 6 months history of severe right nasal congestion and rhinorrhea. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a large right nasopharyngeal-enhancing soft tissue mass obstructing the nasopharyngeal airway and extending into the right posterior nasal cavity, pterygopalatine fossa, nasopalatine fossa and inferior sphenoid sinus . Bilateral retropharyngeal and level II A/B adenopathy was present. Biopsy of the mass showed infiltrating mature lymphocytes and neoplastic cells strongly and diffusely positive for EBV-LMP and EBER; CPS PD-L1 was >20. The patient was diagnosed with T4N1 EBV-positive undifferentiated non-keratinizing NPC and started on 7 weeks of curative-intent radiation with concurrent chemotherapy. Radiation was given as 70 Gy in 35 fractions to the gross tumor and 56 Gy to the bilateral nodes. Intravenous (IV) cisplatin was given concurrently on days 1, 22 and 43 at 100 mg/m2. After completion, adjuvant chemotherapy with daily infusional fluorouracil 1000 mg/m2 for four days and IV cisplatin 80 mg/m2 was given for 3 cycles, with cisplatin omitted due to ototoxicity the last cycle.\nPost-treatment MRI scans suggested complete response . He was placed on thyroid hormone replacement for post-treatment hypothyroidism. At 6 months post-adjuvant chemotherapy, the patient developed right thigh pain. Radiographs showed periosteal reaction in the distal femoral diaphysis and, as the patient was a competitive ice hockey player, this was considered likely a stress fracture. A subsequent biopsy was negative for malignancy. The discomfort persisted and worsened, with two-years post-treatment MRI scan of the femur showing worsening of aggressive bony changes and the appearance of new lesions suggestive of osteomyelitis or metastatic cancer. A PET scan performed 29 months post-treatment showed multifocal bony lesions and multiple hypermetabolic lymph nodes in the chest, abdomen and retroperitoneum without evidence of disease recurrence in the primary nasopharyngeal site . Biopsy of the right femur confirmed EBV-positive metastatic carcinoma.\nThe patient had moderately severe chronic right thigh pain, hemoglobin was 70 g/L, and serum EBV DNA titer was 678,000 IU/ml . Treatment was initiated with analgesics, packed red cell transfusion, palliative radiation 2000 Gy in 5 fractions to the femur, zoledronic acid 4 mg IV, and gemcitabine/cisplatin chemotherapy on a 21 day schedule. There was rapid improvement in the patient’s pain and a CT of the abdomen and pelvis following cycle 4 chemotherapy demonstrated complete resolution of the retroperitoneal and pelvic metastatic adenopathy . EBV titers nadired at 4000 IU/ml at chemotherapy cycle 5, and then began to slowly increase . Following cycle 7, the patient’s thigh pain recurred and he also developed progressive anemia which required transfusion. His energy level progressively deteriorated and he required wheelchair assistance. PET/CT after cycle 8 demonstrated cancer progression with new intrathoracic, retroperitoneal, and pelvic nodal lesions and left iliac bony lesion .\nChemotherapy was discontinued, zoledronic acid was maintained, and the patient was switched to 200 mg pembrolizumab every 21 days. Improvement in hemoglobin level were seen and the patient reported decreased pain and increased energy level after cycle 1. A CT scan following cycle 5 showed size reduction of lymph nodes in the chest, abdomen, and pelvis and stable bony metastasis in the pelvis. By cycle 6, the patient was able to engage in full range of physical activities and by cycle 10, his EBV titer was undetectable . He appeared well with no signs, symptoms, or abnormal blood work suggesting disease progression, and did not experience any obvious immune-mediated toxicities. Subsequent CT results to date show only stable healed bony metastasis .\nPembrolizumab was discontinued after 31 months (46 cycles). The patient is currently being surveilled quarterly with EBV serology and CT imaging, and receives maintenance zoledronic acid. Almost 2 years after discontinuing pembrolizumab, his physical examination, blood work, and CT are unremarkable, EBV levels are undetectable, and he has resumed playing competitive ice hockey. The patient’s treatment timeline and EBV titers are summarized in ; , respectively.", + "fulltext_subclaims": [ + "The patient is a 15-year-old previously healthy male.", + "The patient had a 6 months history of severe right nasal congestion and rhinorrhea.", + "CT and MRI demonstrated a large right nasopharyngeal-enhancing soft tissue mass.", + "The mass obstructed the nasopharyngeal airway and extended into the right posterior nasal cavity, pterygopalatine fossa, nasopalatine fossa, and inferior sphenoid sinus.", + "Bilateral retropharyngeal and level II A/B adenopathy was present.", + "Biopsy of the mass showed infiltrating mature lymphocytes and neoplastic cells.", + "The neoplastic cells were strongly and diffusely positive for EBV-LMP and EBER.", + "CPS PD-L1 was >20.", + "The patient was diagnosed with T4N1 EBV-positive undifferentiated non-keratinizing NPC.", + "The patient was started on 7 weeks of curative-intent radiation with concurrent chemotherapy.", + "Radiation was given as 70 Gy in 35 fractions to the gross tumor.", + "Radiation was given as 56 Gy to the bilateral nodes.", + "Intravenous cisplatin was given concurrently on days 1, 22, and 43 at 100 mg/m2.", + "Adjuvant chemotherapy with daily infusional fluorouracil 1000 mg/m2 for four days and IV cisplatin 80 mg/m2 was given for 3 cycles.", + "Cisplatin was omitted due to ototoxicity in the last cycle.", + "Post-treatment MRI scans suggested complete response.", + "The patient was placed on thyroid hormone replacement for post-treatment hypothyroidism.", + "At 6 months post-adjuvant chemotherapy, the patient developed right thigh pain.", + "Radiographs showed periosteal reaction in the distal femoral diaphysis.", + "The periosteal reaction was considered likely a stress fracture.", + "A subsequent biopsy was negative for malignancy.", + "The discomfort persisted and worsened.", + "A two-years post-treatment MRI scan of the femur showed worsening of aggressive bony changes.", + "The two-years post-treatment MRI scan showed the appearance of new lesions suggestive of osteomyelitis or metastatic cancer.", + "A PET scan performed 29 months post-treatment showed multifocal bony lesions.", + "The PET scan showed multiple hypermetabolic lymph nodes in the chest, abdomen, and retroperitoneum.", + "There was no evidence of disease recurrence in the primary nasopharyngeal site.", + "Biopsy of the right femur confirmed EBV-positive metastatic carcinoma.", + "The patient had moderately severe chronic right thigh pain.", + "The patient's hemoglobin was 70 g/L.", + "The patient's serum EBV DNA titer was 678,000 IU/ml.", + "Treatment was initiated with analgesics, packed red cell transfusion, palliative radiation 2000 Gy in 5 fractions to the femur, zoledronic acid 4 mg IV, and gemcitabine/cisplatin chemotherapy on a 21 day schedule.", + "There was rapid improvement in the patient’s pain.", + "A CT of the abdomen and pelvis following cycle 4 chemotherapy demonstrated complete resolution of the retroperitoneal and pelvic metastatic adenopathy.", + "EBV titers nadired at 4000 IU/ml at chemotherapy cycle 5.", + "EBV titers began to slowly increase after cycle 5.", + "Following cycle 7, the patient’s thigh pain recurred.", + "The patient developed progressive anemia requiring transfusion.", + "The patient’s energy level progressively deteriorated.", + "The patient required wheelchair assistance.", + "PET/CT after cycle 8 demonstrated cancer progression with new intrathoracic, retroperitoneal, and pelvic nodal lesions.", + "PET/CT after cycle 8 demonstrated a left iliac bony lesion.", + "Chemotherapy was discontinued.", + "Zoledronic acid was maintained.", + "The patient was switched to 200 mg pembrolizumab every 21 days.", + "Improvement in hemoglobin level was seen after cycle 1.", + "The patient reported decreased pain and increased energy level after cycle 1.", + "A CT scan following cycle 5 showed size reduction of lymph nodes in the chest, abdomen, and pelvis.", + "The CT scan showed stable bony metastasis in the pelvis.", + "By cycle 6, the patient was able to engage in full range of physical activities.", + "By cycle 10, the patient’s EBV titer was undetectable.", + "The patient appeared well with no signs, symptoms, or abnormal blood work suggesting disease progression.", + "The patient did not experience any obvious immune-mediated toxicities.", + "Subsequent CT results to date show only stable healed bony metastasis.", + "Pembrolizumab was discontinued after 31 months (46 cycles).", + "The patient is currently being surveilled quarterly with EBV serology and CT imaging.", + "The patient receives maintenance zoledronic acid.", + "Almost 2 years after discontinuing pembrolizumab, the patient’s physical examination, blood work, and CT are unremarkable.", + "Almost 2 years after discontinuing pembrolizumab, the patient’s EBV levels are undetectable.", + "The patient has resumed playing competitive ice hockey." + ], + "summary": "A male patient presented at age 15 with stage IVA EBV-related NPC. Despite response to initial chemoradiation and adjuvant chemotherapy, the patient experienced metastatic cancer relapse in lymph nodes and bone. There was initial response to gemcitabine/cisplatin chemotherapy, but the cancer progressed after 7 cycles. The patient was then switched to pembrolizumab and had a near complete clinical response after 14 cycles. Serum EBV titers have normalized and CT imaging shows only some healed bone metastasis. Retrospective assessment of tumor CPS PD-L1 was >20. Hypothyroidism developed, possibly due to radiation treatment, but otherwise he did not experience any other immune-mediated toxicities on or following treatment, which lasted in total 2 years with 41 cycles. To date, the patient has been observed off pembrolizumab for over one year and is highly functional without evidence of disease progression.", + "summary_subclaims": [ + "The patient is a male.", + "The patient was 15 years old at presentation.", + "The patient had stage IVA EBV-related NPC.", + "The patient had a response to initial chemoradiation.", + "The patient received adjuvant chemotherapy.", + "The patient experienced metastatic cancer relapse in lymph nodes.", + "The patient experienced metastatic cancer relapse in bone.", + "The patient had an initial response to gemcitabine/cisplatin chemotherapy.", + "The cancer progressed after 7 cycles of gemcitabine/cisplatin.", + "The patient was switched to pembrolizumab.", + "The patient had a near complete clinical response after 14 cycles of pembrolizumab.", + "Serum EBV titers have normalized.", + "CT imaging shows only some healed bone metastasis.", + "Retrospective assessment of tumor CPS PD-L1 was >20.", + "Hypothyroidism developed.", + "Hypothyroidism may be due to radiation treatment.", + "The patient did not experience any other immune-mediated toxicities on or following treatment.", + "The total treatment duration was 2 years.", + "The patient received 41 cycles of treatment.", + "The patient has been observed off pembrolizumab for over one year.", + "The patient is highly functional.", + "There is no evidence of disease progression." + ] + }, + { + "id": "multiclinsum_test_587_en.txt", + "fulltext": "A 50-year-old woman with no coronary artery disease risk factors had suffered from transient chest pain, dyspnoea, and paroxysmal neck swelling irrespective of emotional stress for ∼15 years . Since the attacks often developed after meals, especially at full stomach, she took care not to eat too much. At the age of 44, she was admitted to the emergency department for the first time due to acute pulmonary oedema following the aforementioned attacks. Urgent cardiac catheterization showed no significant coronary stenosis and typical apical LV ballooning , and finally she was diagnosed as having TTS. Later, at the age of 45 and 49, she developed the same clinical disorder. Interestingly, the LV wall motion abnormality was localized to the basal region at the second admission and diffusely at the last time (no images available). Moreover, during the second admission, acetylcholine (ACh) provocation testing for coronary spasm was performed with negative results. Although local LV asynergy disappeared spontaneously in each hospitalization, she had frequently suffered from the same attacks after meals and was referred to our hospital for further investigation. She did not have any oral medication during the TTS episodes. On admission, she had no subjective symptoms or objective signs in electrocardiogram (ECG) or echocardiographic examinations. However, abdominal ultrasonography for screening purposes detected a right adrenal mass of 35 mm × 35 mm in size and scintigraphy imaging showed high uptake of M-iodobenzylguanidine in the tumour . Furthermore, urinary catecholamine levels (especially normetanephrine) were markedly elevated . Since pheochromocytoma was highly suspected from these data, we paid attention not to perform any contrast studies that could cause adrenal crisis. This tumour was urgently removed surgically and histological diagnosis of norepinephrine-secreting pheochromocytoma was made . Ten days after the operation, when urinary catecholamine levels were normalized , we performed cardiac catheterization and ACh provocation testing. As shown in , intracoronary administration of ACh (20, 50, and 100 μg) into the left coronary artery (LCA) and that of ACh (25 and 50 μg) into the right coronary artery induced epicardial coronary spasm accompanied by chest pain and ischaemic ECG changes. Chest pain, ischaemic ECG changes, and myocardial lactate production were already noted at the timing of administration of 20 μg of ACh into the LCA before the occurrence of epicardial coronary spasm at 100 μg, indicating that microvascular spasm (MVS) preceded epicardial coronary spasm. Thus, we diagnosed that she had both epicardial coronary spasm and MVS, and initiated drug therapy with a calcium antagonist (benidipine 8 mg/day). After discharge from our hospital, she experienced no episode of postprandial attacks and her urinary catecholamine levels remained low, indicating that she was free of catecholamine surges from pheochromocytoma . She again underwent a scheduled follow-up ACh provocation testing at 18 months after the operation. Calcium antagonist was discontinued 72 h before the provocation testing. Interestingly, epicardial coronary spasm was no longer induced, whereas MVS persisted .", + "fulltext_subclaims": [ + "The patient is a 50-year-old woman.", + "She had no coronary artery disease risk factors.", + "She had suffered from transient chest pain, dyspnoea, and paroxysmal neck swelling irrespective of emotional stress for ∼15 years.", + "The attacks often developed after meals, especially at full stomach.", + "She took care not to eat too much.", + "At the age of 44, she was admitted to the emergency department for the first time due to acute pulmonary oedema following the aforementioned attacks.", + "Urgent cardiac catheterization showed no significant coronary stenosis.", + "Urgent cardiac catheterization showed typical apical LV ballooning.", + "She was diagnosed as having TTS.", + "At the age of 45, she developed the same clinical disorder.", + "At the age of 49, she developed the same clinical disorder.", + "The LV wall motion abnormality was localized to the basal region at the second admission.", + "The LV wall motion abnormality was diffusely at the last time.", + "During the second admission, acetylcholine (ACh) provocation testing for coronary spasm was performed with negative results.", + "Local LV asynergy disappeared spontaneously in each hospitalization.", + "She had frequently suffered from the same attacks after meals.", + "She was referred to our hospital for further investigation.", + "She did not have any oral medication during the TTS episodes.", + "On admission, she had no subjective symptoms.", + "On admission, she had no objective signs in electrocardiogram (ECG) or echocardiographic examinations.", + "Abdominal ultrasonography detected a right adrenal mass of 35 mm × 35 mm in size.", + "Scintigraphy imaging showed high uptake of M-iodobenzylguanidine in the tumour.", + "Urinary catecholamine levels (especially normetanephrine) were markedly elevated.", + "Pheochromocytoma was highly suspected from these data.", + "We paid attention not to perform any contrast studies that could cause adrenal crisis.", + "This tumour was urgently removed surgically.", + "Histological diagnosis of norepinephrine-secreting pheochromocytoma was made.", + "Ten days after the operation, when urinary catecholamine levels were normalized, we performed cardiac catheterization and ACh provocation testing.", + "Intracoronary administration of ACh (20, 50, and 100 μg) into the left coronary artery (LCA) and that of ACh (25 and 50 μg) into the right coronary artery induced epicardial coronary spasm accompanied by chest pain and ischaemic ECG changes.", + "Chest pain, ischaemic ECG changes, and myocardial lactate production were already noted at the timing of administration of 20 μg of ACh into the LCA before the occurrence of epicardial coronary spasm at 100 μg.", + "We diagnosed that she had both epicardial coronary spasm and MVS.", + "Drug therapy with a calcium antagonist (benidipine 8 mg/day) was initiated.", + "After discharge from our hospital, she experienced no episode of postprandial attacks.", + "Her urinary catecholamine levels remained low, indicating that she was free of catecholamine surges from pheochromocytoma.", + "She again underwent a scheduled follow-up ACh provocation testing at 18 months after the operation.", + "Calcium antagonist was discontinued 72 h before the provocation testing.", + "Epicardial coronary spasm was no longer induced.", + "MVS persisted." + ], + "summary": "A 50-year-old woman was referred with a chief complaint of transient chest pain, dyspnoea, and paroxysmal thyroid swelling that usually developed after meals. In the past, she had been admitted to emergency rooms three times due to pulmonary oedema following the above attacks. Serial cardiac catheterizations showed normal coronary arteries and morphologically different types of LV dysfunction each time; apical LV ballooning at the first, basal LV ballooning at the second, and diffuse LV hypokinesis at the last admission. Acetylcholine (ACh) provocation testing for coronary vasospasm was negative at the second admission. During hospitalization in our department, abdominal ultrasonography for screening detected a right adrenal mass and the urinary normetanephrine level was increased. The adrenal tumour was urgently removed surgically and finally she was diagnosed as having norepinephrine-secreting pheochromocytoma. Acetylcholine testing was again performed just after the operation, showing both epicardial and microvascular coronary spasms. Since the operation, she has been free of symptoms. Importantly, ACh testing at 1-year follow-up showed that epicardial spasm was no longer noted, whereas coronary microvascular spasm persisted.", + "summary_subclaims": [ + "A 50-year-old woman was referred with a chief complaint of transient chest pain, dyspnoea, and paroxysmal thyroid swelling that usually developed after meals.", + "She had been admitted to emergency rooms three times due to pulmonary oedema following the above attacks.", + "Serial cardiac catheterizations showed normal coronary arteries.", + "Apical LV ballooning was noted at the first admission.", + "Basal LV ballooning was noted at the second admission.", + "Diffuse LV hypokinesis was noted at the last admission.", + "Acetylcholine (ACh) provocation testing for coronary vasospasm was negative at the second admission.", + "Abdominal ultrasonography detected a right adrenal mass.", + "The urinary normetanephrine level was increased.", + "The adrenal tumour was urgently removed surgically.", + "She was diagnosed as having norepinephrine-secreting pheochromocytoma.", + "Acetylcholine testing performed just after the operation showed both epicardial and microvascular coronary spasms.", + "Since the operation, she has been free of symptoms.", + "ACh testing at 1-year follow-up showed that epicardial spasm was no longer noted.", + "Coronary microvascular spasm persisted at 1-year follow-up." + ] + }, + { + "id": "multiclinsum_test_2397_en.txt", + "fulltext": "A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago.\nThe patient’s symptoms started after the trauma, and the abdominal pain worsened over time.\nThe patient had no previous medical history.\nThe patient did not smoke and had no relevant family history.\nAt the time of admission, the patient’s Glasgow Coma scale was 15/15, blood pressure was 120/70 mmHg, body temperature was 36.3 °C, heart rate was 94 bpm, respiratory rate was 20 breaths per minute, and oxygen saturation in room air was 98%. A physical examination revealed tenderness without rebound pain over the left upper quadrant.\nThe results of the laboratory investigations were as follows: white blood cell count, 21.8 × 103/μL (normal range, 4.8-10.8); neutrophils, 86.8% (50-75); hemoglobin, 13.1 g/dL (12-18); platelet count, 172 × 103/μL (130-450); fibrin degradation products, 16.4 μg/mL (0-5); D-dimer, 6.19 mg/L (0-0.55); creatinine, 1.37 mg/dL (0.5-1.3); modification of diet in renal disease estimated glomerular filtration rate (eGFR), 66.938 mL/min/1.73 m2 (71.11-214.2); and chronic kidney disease epidemiology collaboration eGFR, 74.24 mL/min/1.73 m2 (79.1-157.0). Lactate, fibrinogen assay, activated partial thromboplastin time, and prothrombin time (PT) values were within normal limits.\nRadiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney , occlusion of the branches of the splenic artery with infarction of the central portion of the spleen , a small amount of hemoperitoneum, and left adrenal hematoma .\nThe percutaneous transluminal angioplasty attempted to revascularize the left renal artery occlusion failed due to difficulty in passing the wire through the total occlusion. In addition, considering the acute splenic and renal infarctions with multivascular occlusion in this young male patient without underlying disease, a laboratory evaluation of hypercoagulability was performed to exclude the possibility of other diseases. Lupus anticoagulant (LA), antinuclear antibody (ANA) titer, antineutrophil cytoplasmic antibody (ANCA), anti-cardiolipin (aCL) immunoglobulin M (IgM) and immunoglobulin G (IgG), and anti-β2-glycoprotein I (GPI) IgM and IgG tests were performed.\nLaboratory tests were reported on day 7 after the injury and were as follows: LA, weak positive (1.41) (0-1.30, negative; 1.31-1.50, weak positive; 1.51-2.0, moderate positive; > 2.0, strong positive; LA1 screening reagent, LA2 confirmation reagent; Siemens Healthcare, Marburg, Germany); ANA titer, negative (< 1:80, negative; ANA HEp-2 standard kit; Aesku Diagnostics, Wendelsheim, Germany); ANCA, negative (< 1:20, negative; ANCA Ethanol; Aesku Diagnostics, Wendelsheim, Germany); aCL IgM, negative (< 7 U/mL, negative); aCL IgG, negative (< 10 U/mL, negative; aCL IgM, IgG; Orgentec Diagnostika, Mainz, Germany); anti-β2-GPI IgM, negative (< 7 U/mL, negative); and anti-β2-GPI IgG, negative (< 7 U/mL, negative; Phadia EliA; Thermofisher, Freiburg, Germany).", + "fulltext_subclaims": [ + "A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago.", + "The patient’s symptoms started after the trauma, and the abdominal pain worsened over time.", + "The patient had no previous medical history.", + "The patient did not smoke and had no relevant family history.", + "At the time of admission, the patient’s Glasgow Coma scale was 15/15.", + "At the time of admission, the patient’s blood pressure was 120/70 mmHg.", + "At the time of admission, the patient’s body temperature was 36.3 °C.", + "At the time of admission, the patient’s heart rate was 94 bpm.", + "At the time of admission, the patient’s respiratory rate was 20 breaths per minute.", + "At the time of admission, the patient’s oxygen saturation in room air was 98%.", + "A physical examination revealed tenderness without rebound pain over the left upper quadrant.", + "The white blood cell count was 21.8 × 103/μL.", + "The neutrophil percentage was 86.8%.", + "The hemoglobin level was 13.1 g/dL.", + "The platelet count was 172 × 103/μL.", + "The fibrin degradation products level was 16.4 μg/mL.", + "The D-dimer level was 6.19 mg/L.", + "The creatinine level was 1.37 mg/dL.", + "The modification of diet in renal disease estimated glomerular filtration rate was 66.938 mL/min/1.73 m2.", + "The chronic kidney disease epidemiology collaboration estimated glomerular filtration rate was 74.24 mL/min/1.73 m2.", + "Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney.", + "Radiological investigations revealed occlusion of the branches of the splenic artery with infarction of the central portion of the spleen.", + "Radiological investigations revealed a small amount of hemoperitoneum.", + "Radiological investigations revealed a left adrenal hematoma.", + "The percutaneous transluminal angioplasty attempted to revascularize the left renal artery occlusion failed due to difficulty in passing the wire through the total occlusion.", + "A laboratory evaluation of hypercoagulability was performed.", + "The lupus anticoagulant test was weak positive (1.41).", + "The antinuclear antibody titer test was negative.", + "The antineutrophil cytoplasmic antibody test was negative.", + "The anti-cardiolipin immunoglobulin M test was negative.", + "The anti-cardiolipin immunoglobulin G test was negative.", + "The anti-β2-glycoprotein I immunoglobulin M test was negative.", + "The anti-β2-glycoprotein I immunoglobulin G test was negative." + ], + "summary": "A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago. He had no medical history. Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney and occlusion of branches of the splenic artery with infarction of the central portion of the spleen. Attempted revascularization of the left renal artery occlusion through percutaneous transluminal angioplasty failed due to difficulty in passing the wire through the total occlusion. Considering the presence of acute multivascular occlusions in a young man with low cardiovascular risk, additional laboratory tests were performed to evaluate hypercoagulability. The results suggested a high possibility of antiphospholipid syndrome. Treatment with a subcutaneous injection of enoxaparin was started and changed to oral warfarin after two weeks. The diagnosis was confirmed, and he continued to visit the rheumatology outpatient clinic while taking warfarin.", + "summary_subclaims": [ + "A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago.", + "He had no medical history.", + "Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney.", + "Radiological investigations revealed occlusion of branches of the splenic artery with infarction of the central portion of the spleen.", + "Attempted revascularization of the left renal artery occlusion through percutaneous transluminal angioplasty failed due to difficulty in passing the wire through the total occlusion.", + "Additional laboratory tests were performed to evaluate hypercoagulability.", + "The results suggested a high possibility of antiphospholipid syndrome.", + "Treatment with a subcutaneous injection of enoxaparin was started.", + "Treatment was changed to oral warfarin after two weeks.", + "The diagnosis was confirmed.", + "He continued to visit the rheumatology outpatient clinic while taking warfarin." + ] + }, + { + "id": "multiclinsum_test_2040_en.txt", + "fulltext": "A 43-yr-old, 66 kg, 175 cm man was to undergo gastrectomy for a tumor in the stomach. He had no history of hypertension, myocardial infarction,or angina pectoris,but with a smoking history(10 packs year).His physical examination was normal. Preoperative resting electrocardiogram (ECG) and echocardiogram(UCG) were within normal limits. Laboratory data revealed no abnormalities.\nNo premedication was given. After the patient,s arrival in the operating room, intravenous access was established. Lead II and V5 of the ECG were monitored. Blood pressure (BP) was 128/70 mmHg and heart rate(HR) 75 beats/min. An ultrasound-guided subcostal TAP block was performed bilaterally . Each hemi abdomen was injected with 20 ml 0.3% ropivacaine to give a dual block from T6-T9. TAP block was uneventful without heart rate and blood pressure variations. After 30 min, general anesthesia was induced, then it was maintained with sevoflurane inhalation, target controlled infusion (TCI) remifentanil and given sufentanil and cisatracurium intermittently. The patient was mechanically ventilated with a tidal volume of 500 ml and respiratory rate of 10 breaths/min to maintain PetCO2 at 35–40 mmHg under end-tidal CO2 monitoring. Arterial BP was continuously monitored via a left radial artery catheter.\nTwo hours after start of the operation, when the surgeons were dissecting para gastric lymph node, ST segment elevation in lead II was noted and lead V5 showed no abnormalities. The change recovered abruptly without treatment 30 s later. When it happened, SpO2 was 100%, end-tidal sevoflurane concentration was 1.3% and no obvious hemorrhage. Except for this, the patient,s course during 4 h of operation was uneventful: BP was about 100/70 mmHg, HR about 70 beats/min, body temperature about 36.5 °C and estimated blood loss was less than 300 ml. Four hours after start of the operation, the arterial BP was 88/55 mmHg and aramine 0.4 mg was given intravenously. The BP increased to 110/65 mmHg without HR change. Approximately 5 min later, the ECG showed premature ventricular contractions and a marked ST segment elevation again . Ventricular tachycardia and fibrillation were subsequently noticed with BP decreased to 32/14 mmHg, and electric defibrillation was initiated with repeated infusions of epinephrin. Within approximately 2 min, the ECG returned to sinus rhythm and BP gradually to normal. The patient remained hemodynamically stable for the remainder of the operation. Following the operation, he was transferred to the cardiac care unit (CCU) in our hospital. Serial ECGs and cardiac enzyme studies showed no abnormalities, thus ruling out myocardial infarction and CAS was diagnosed. The patient suffered no further cardiac attacks during his hospital stay. Consent was obtained from the patient to publish this case report.", + "fulltext_subclaims": [ + "A 43-yr-old, 66 kg, 175 cm man was to undergo gastrectomy for a tumor in the stomach.", + "He had no history of hypertension, myocardial infarction, or angina pectoris.", + "He had a smoking history of 10 packs year.", + "Preoperative resting electrocardiogram (ECG) and echocardiogram (UCG) were within normal limits.", + "Laboratory data revealed no abnormalities.", + "No premedication was given.", + "After the patient's arrival in the operating room, intravenous access was established.", + "Lead II and V5 of the ECG were monitored.", + "Blood pressure (BP) was 128/70 mmHg and heart rate (HR) 75 beats/min.", + "An ultrasound-guided subcostal TAP block was performed bilaterally.", + "Each hemi abdomen was injected with 20 ml 0.3% ropivacaine to give a dual block from T6-T9.", + "TAP block was uneventful without heart rate and blood pressure variations.", + "After 30 min, general anesthesia was induced.", + "General anesthesia was maintained with sevoflurane inhalation, target controlled infusion (TCI) remifentanil, and given sufentanil and cisatracurium intermittently.", + "The patient was mechanically ventilated with a tidal volume of 500 ml and respiratory rate of 10 breaths/min.", + "End-tidal CO2 monitoring was used to maintain PetCO2 at 35–40 mmHg.", + "Arterial BP was continuously monitored via a left radial artery catheter.", + "Two hours after start of the operation, when the surgeons were dissecting para gastric lymph node, ST segment elevation in lead II was noted.", + "Lead V5 showed no abnormalities.", + "The change recovered abruptly without treatment 30 s later.", + "When it happened, SpO2 was 100%.", + "End-tidal sevoflurane concentration was 1.3%.", + "There was no obvious hemorrhage.", + "The patient's course during 4 h of operation was uneventful.", + "BP was about 100/70 mmHg.", + "HR was about 70 beats/min.", + "Body temperature was about 36.5 °C.", + "Estimated blood loss was less than 300 ml.", + "Four hours after start of the operation, the arterial BP was 88/55 mmHg.", + "Aramine 0.4 mg was given intravenously.", + "The BP increased to 110/65 mmHg without HR change.", + "Approximately 5 min later, the ECG showed premature ventricular contractions and a marked ST segment elevation again.", + "Ventricular tachycardia and fibrillation were subsequently noticed with BP decreased to 32/14 mmHg.", + "Electric defibrillation was initiated with repeated infusions of epinephrin.", + "Within approximately 2 min, the ECG returned to sinus rhythm.", + "BP gradually returned to normal.", + "The patient remained hemodynamically stable for the remainder of the operation.", + "Following the operation, he was transferred to the cardiac care unit (CCU) in our hospital.", + "Serial ECGs and cardiac enzyme studies showed no abnormalities.", + "This ruled out myocardial infarction.", + "CAS was diagnosed.", + "The patient suffered no further cardiac attacks during his hospital stay.", + "Consent was obtained from the patient to publish this case report." + ], + "summary": "In this case report, we present a case of a patient with CAS accompanied by ventricular fibrillation under general anesthesia with TAP block.", + "summary_subclaims": [ + "The patient had CAS.", + "The patient had ventricular fibrillation.", + "The patient was under general anesthesia.", + "The patient had a TAP block." + ] + }, + { + "id": "multiclinsum_test_652_en.txt", + "fulltext": "70 years old female was admitted to the hospital with epigastric pain, fevers and elevated white cell count. Abdominal CT scan demonstrated evidence of duodenal diverticulitis and she was started on broad-spectrum IV antibiotics . Overnight, her clinical condition had worsened with persistent tachycardia, increase in white count, fevers and signs of peritonitis on exam. Interval CT revealed significant amount of air and fluid in the abdomen concerning for free perforation. Patient was consented for exploration and possible pancreatoduodenectomy. During surgery, large perforation of the 4 cm juxtapapillary duodenal diverticulum originating from posterior-medial wall with peritonitis was found . Due to very medial location in close proximity to insertion of the ampulla, segmental resection was not possible and decision was made to proceed with pancreatoduodenectomy. Pathology confirmed perforation originating from duodenal diverticulum with no additional abnormal findings. Patient tolerated procedure without complications and was discharged home after 10-day hospital stay. She is doing well at 2 months follow up and has returned to work.", + "fulltext_subclaims": [ + "The patient is a 70 years old female.", + "She was admitted to the hospital with epigastric pain.", + "She had fevers.", + "She had an elevated white cell count.", + "Abdominal CT scan demonstrated evidence of duodenal diverticulitis.", + "She was started on broad-spectrum IV antibiotics.", + "Overnight, her clinical condition had worsened.", + "She had persistent tachycardia.", + "There was an increase in white count.", + "She had fevers.", + "She had signs of peritonitis on exam.", + "Interval CT revealed significant amount of air and fluid in the abdomen.", + "The CT findings were concerning for free perforation.", + "The patient was consented for exploration and possible pancreatoduodenectomy.", + "During surgery, a large perforation of the 4 cm juxtapapillary duodenal diverticulum was found.", + "The diverticulum originated from the posterior-medial wall.", + "There was peritonitis.", + "Segmental resection was not possible.", + "The decision was made to proceed with pancreatoduodenectomy.", + "Pathology confirmed perforation originating from duodenal diverticulum.", + "There were no additional abnormal findings.", + "The patient tolerated the procedure without complications.", + "She was discharged home after a 10-day hospital stay.", + "She is doing well at 2 months follow up.", + "She has returned to work." + ], + "summary": "70 years old female was admitted to the hospital with epigastric pain, fevers and elevated white cell count. Abdominal CT scan demonstrated evidence of perforated duodenal diverticulitis which failed to improve with IV antibiotics. Emergent pancreatoduodenectomy was performed with full recovery and uncomplicated hospital stay.", + "summary_subclaims": [ + "The patient is a 70 years old female.", + "The patient was admitted to the hospital with epigastric pain.", + "The patient had fevers.", + "The patient had an elevated white cell count.", + "Abdominal CT scan demonstrated evidence of perforated duodenal diverticulitis.", + "The perforated duodenal diverticulitis failed to improve with IV antibiotics.", + "Emergent pancreatoduodenectomy was performed.", + "The patient had full recovery.", + "The hospital stay was uncomplicated." + ] + }, + { + "id": "multiclinsum_test_36_en.txt", + "fulltext": "A 21-year-old virgin female presented to our hospital with complaints of mild abdominal pain, hirsutism, and oligomenorrhea. Her medical history was of interest. The patient had menarche at the age of 13. However, 1 year before admission to our institution, she experienced hirsutism and oligomenorrhea with menstrual cycles of more than 60 days apart. Therefore she visited an external gynecologic clinic where she was prescribed oral contraceptives to regulate her periods. The patient claimed to observe a mild regression in the symptoms with no further examinations. However, details and data supporting her previous admission were not available. The patient’s mother had a hysterectomy several years ago due to the diagnosis of multiple leiomyomas. Other than that, family and medical history were unremarkable.\nOn presentation to our institution, physical examination revealed abdominal tenderness with a palpable pelvic mass and mild hirsutism in the thigh. Her body mass index (BMI) was 19.1 kg/m² (height: 150 cm, weight: 43 kg). Interestingly, ultrasonography demonstrated a large left ovarian mass measuring 154 × 104 mm, and compressing the uterus . No pelvic enlarged lymph nodes or Douglas pouch effusion were observed, and computed tomography (CT) scan revealed no other lesions. Due to the large size of the ovarian mass and the risk of compressing the uterus and the adjacent organs, a unilateral salpingo-oophorectomy was performed. Macroscopic examination revealed a large, well-circumscribed lobulated solid yellow-brownish mass, measuring approximately 15 × 9 cm . Cut sections demonstrated bright orange-yellowish nodules with scattered foci of necrosis and hemorrhage and a rich-vasculature capsule .\nMicroscopic examination demonstrated diffuse and nodular proliferation of medium-sized to large polygonal neoplastic cells with pale to granular eosinophilic cytoplasm, small round nuclei, and mild atypia . The cells were separated by a vascular stroma, with no evidence of capsular invasion . Few scattered foci of necrosis and hemorrhage were observed , whereas the mitotic rate was less than 2 per 10 high-power fields, and crystals of Reinke were not observed. Thus final diagnosis was a steroid cell tumor-not otherwise specified (SCT-NOS). Immunohistochemistry revealed positivity for Inhibin-a, Calretinin, and ER , whereas CD99, PR, and AR showed negative expression, confirming the aforementioned diagnosis, and expression of Ki-67 was estimated to be less than 20% . Molecular and additional techniques were not available. Following surgery, the patient was hospitalized for 5 days and discharged later with a stable condition and normal laboratory and radiologic results. However, 2 weeks later, she was admitted back to our hospital due to an intermittent localized pain in the right iliac fossa. Full body computed tomography (CT) scan demonstrated a small right ovarian mass that was reported as a benign functional cyst by an expert radiologist and an oncologist, with no other lesions. Due to the patient’s young age and fertility desire, the medical decision was to stay monitored radiographically with no surgical interventions. Two months later, a CT scan demonstrated a prominent decrease in the cyst’s size supporting its benign functional origin. And since her last visit, the patient has been in a stable condition according to clinical and radiologic monitoring with no virilization symptoms. A timeline of the patient’s case can be seen in Fig. .", + "fulltext_subclaims": [ + "The patient is a 21-year-old virgin female.", + "The patient presented with mild abdominal pain, hirsutism, and oligomenorrhea.", + "The patient had menarche at the age of 13.", + "One year before admission, she experienced hirsutism and oligomenorrhea with menstrual cycles of more than 60 days apart.", + "She was prescribed oral contraceptives at an external gynecologic clinic.", + "The patient claimed to observe a mild regression in the symptoms.", + "The patient’s mother had a hysterectomy due to multiple leiomyomas.", + "On presentation, physical examination revealed abdominal tenderness with a palpable pelvic mass and mild hirsutism in the thigh.", + "Ultrasonography demonstrated a large left ovarian mass measuring 154 × 104 mm.", + "The ovarian mass was compressing the uterus.", + "Computed tomography (CT) scan revealed no other lesions.", + "A unilateral salpingo-oophorectomy was performed.", + "Macroscopic examination revealed a large, well-circumscribed lobulated solid yellow-brownish mass, measuring approximately 15 × 9 cm.", + "Cut sections demonstrated bright orange-yellowish nodules with scattered foci of necrosis and hemorrhage.", + "Microscopic examination demonstrated diffuse and nodular proliferation of medium-sized to large polygonal neoplastic cells.", + "The cells had pale to granular eosinophilic cytoplasm, small round nuclei, and mild atypia.", + "The cells were separated by a vascular stroma, with no evidence of capsular invasion.", + "Few scattered foci of necrosis and hemorrhage were observed.", + "The mitotic rate was less than 2 per 10 high-power fields.", + "Crystals of Reinke were not observed.", + "The final diagnosis was a steroid cell tumor-not otherwise specified (SCT-NOS).", + "Immunohistochemistry revealed positivity for Inhibin-a, Calretinin, and ER.", + "CD99, PR, and AR showed negative expression.", + "Expression of Ki-67 was estimated to be less than 20%.", + "Molecular and additional techniques were not available.", + "The patient was hospitalized for 5 days and discharged with a stable condition.", + "Two weeks later, she was admitted back to the hospital due to intermittent localized pain in the right iliac fossa.", + "A full body CT scan demonstrated a small right ovarian mass reported as a benign functional cyst.", + "The medical decision was to stay monitored radiographically with no surgical interventions.", + "A CT scan two months later demonstrated a prominent decrease in the cyst’s size.", + "The patient has been in a stable condition according to clinical and radiologic monitoring.", + "The patient has had no virilization symptoms since her last visit." + ], + "summary": "We report a case of a 21-year-old virgin female who presented to our hospital with complaints of mild abdominal pain, hirsutism, and oligomenorrhea for more than a year. Before her current admission, the patient had attended an external gynecologic clinic where she had been prescribed oral contraceptives to regulate her periods. Nevertheless, on presentation to our institution, physical examination revealed abdominal tenderness with a palpable pelvic mass and mild hirsutism in the thigh. Ultrasonography demonstrated a large left ovarian mass measuring 154 × 104 mm, and compressing the uterus. Therefore, a unilateral salpingo-oophorectomy was performed, and interestingly, pathologic examination of the large aforementioned mass alongside with immunohistochemical correlation revealed the diagnosis of a large ovarian steroid cell tumor-not otherwise specified with a unique combination of benign and malignant features.", + "summary_subclaims": [ + "The patient is a 21-year-old virgin female.", + "She presented with mild abdominal pain, hirsutism, and oligomenorrhea for more than a year.", + "Before her current admission, she had been prescribed oral contraceptives to regulate her periods.", + "On presentation to our institution, physical examination revealed abdominal tenderness with a palpable pelvic mass.", + "Ultrasonography demonstrated a large left ovarian mass measuring 154 × 104 mm.", + "The mass was compressing the uterus.", + "A unilateral salpingo-oophorectomy was performed.", + "Pathologic examination of the mass revealed the diagnosis of a large ovarian steroid cell tumor-not otherwise specified.", + "The tumor had a unique combination of benign and malignant features." + ] + }, + { + "id": "multiclinsum_test_380_en.txt", + "fulltext": "A 55-year-old woman presented gross haematuria for several days. She had history of storage lower urinary tract symptoms (LUTS) since undergoing quadrantectomy surgery for breast cancer 3 years previously. She referred previous treatment with leuprorelin 3.75 mg/2 ml. She was an ex-smoker with a cigarette consumption of maximum ten a day. She interrupted smoking when she was diagnosed breast cancer. She referred past episodes of haematuria and storage LUTS that she always treated with antibiotics even if urine culture was negative. In April 2020, she came to our ambulatory of urology. She showed us a recent urine culture negative for infections and urinary cytology negative for malignant cells. Cystoscopy was performed, and it demonstrated an extensive whitish plaque area on the fundus, the dome, left emi-trigone, and left bladder wall. It extended near the left ureteric orifice without interesting it . Right orifice was completely spared . The efflux from both the ureteric orifices was normal. The mucosa underneath the plaques was inflamed . Multiple biopsies were performed. A net margin separated sane mucosa from pathological plagues. The histology of the affected area revealed keratinizing squamous metaplasia and focal low grade epithelial dysplasia . With these collected data, the main objective of our case study was to describe individual situation of a woman affected by diffuse leukoplakia of the bladder ostium-sparing with previous treatment with leuprorelin 3.75 mg/2 ml for breast cancer and to show safety of follow-up by cystoscopy and biopsy.", + "fulltext_subclaims": [ + "The patient is a 55-year-old woman.", + "She presented with gross haematuria for several days.", + "She had a history of storage lower urinary tract symptoms since undergoing quadrantectomy surgery for breast cancer 3 years previously.", + "She referred previous treatment with leuprorelin 3.75 mg/2 ml.", + "She was an ex-smoker with a cigarette consumption of maximum ten a day.", + "She interrupted smoking when she was diagnosed with breast cancer.", + "She referred past episodes of haematuria and storage LUTS that she always treated with antibiotics even if urine culture was negative.", + "In April 2020, she came to the ambulatory of urology.", + "A recent urine culture was negative for infections.", + "Urinary cytology was negative for malignant cells.", + "Cystoscopy demonstrated an extensive whitish plaque area on the fundus, the dome, left emi-trigone, and left bladder wall.", + "The plaque area extended near the left ureteric orifice without interesting it.", + "The right ureteric orifice was completely spared.", + "The efflux from both the ureteric orifices was normal.", + "The mucosa underneath the plaques was inflamed.", + "Multiple biopsies were performed.", + "A net margin separated sane mucosa from pathological plaques.", + "The histology of the affected area revealed keratinizing squamous metaplasia and focal low grade epithelial dysplasia.", + "The main objective of the case study was to describe the individual situation of a woman affected by diffuse leukoplakia of the bladder ostium-sparing.", + "The case study aimed to show the safety of follow-up by cystoscopy and biopsy." + ], + "summary": "A 55-year-old woman came to our attention in April 2020 referring haematuria, frequency and urgency. The patient referred previous treatment with leuprorelin 3.75 mg/2 ml for breast cancer three years ago. Urine culture was performed and resulted always negative for pathogens. Cystoscopy revealed a whitish plaque lesion on the fundus, dome, trigone, and left lateral wall of the bladder. Histology of the biopsy confirmed the diagnosis of leukoplakia of the bladder. The plan is to follow her up repeating a cystoscopy every three months and biopsy in 6 months. Literature search revealed very little information on pathogenesis and prognosis of this condition due to its rare occurrence. The main objective of our case study was to describe individual situation of a woman affected by diffuse leukoplakia of the bladder ostium-sparing with a previous treatment with leuprorelin 3.75 mg/2 ml for breast cancer and to show safety of follow-up by cystoscopy and biopsy.", + "summary_subclaims": [ + "The patient is a 55-year-old woman.", + "She came to our attention in April 2020.", + "She referred haematuria.", + "She referred frequency.", + "She referred urgency.", + "The patient referred previous treatment with leuprorelin 3.75 mg/2 ml for breast cancer three years ago.", + "Urine culture was performed.", + "Urine culture resulted always negative for pathogens.", + "Cystoscopy revealed a whitish plaque lesion on the fundus, dome, trigone, and left lateral wall of the bladder.", + "Histology of the biopsy confirmed the diagnosis of leukoplakia of the bladder.", + "The plan is to follow her up repeating a cystoscopy every three months.", + "The plan includes a biopsy in 6 months.", + "Literature search revealed very little information on pathogenesis and prognosis of this condition due to its rare occurrence.", + "The main objective of our case study was to describe individual situation of a woman affected by diffuse leukoplakia of the bladder ostium-sparing with a previous treatment with leuprorelin 3.75 mg/2 ml for breast cancer.", + "The main objective was to show safety of follow-up by cystoscopy and biopsy." + ] + }, + { + "id": "multiclinsum_test_1094_en.txt", + "fulltext": "The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. Bile duct obstruction due to a liver metastasis caused obstructive jaundice and acute cholangitis, which resulted in emergency hospitalization. On magnetic resonance imaging , a 3.5 cm mass in the biliary hilum caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. Despite several attempts at biliary drainage (branch of B3 and B2, B5, B7) via ERCP, obstructive jaundice was not improved. The patient was emergently hospitalized again because of acute cholangitis with a 39 °C fever and epigastric pain, although bile duct plastic stents (PS) had been placed in the left intrahepatic bile duct (branch of B3 and B2) and right intrahepatic bile duct (B5 and B7) . Repeated ERCP and biliary drainage were performed, had no effect as shown on the CT . In this case, many of biliary branches were divided by the obstruction at hilar biliary. Only by 2D image, it was hard to identify the relation between dilated biliary branches and drainage tube placed. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, 3D images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). We used the 3D images for preoperative planning and performed biliary drainage using them as an intraoperative reference.\nResidual dilation was observed in the left intrahepatic bile duct (B3). Although the PS was allowing slight decompression of the left intrahepatic bile duct (B2), marked biliary dilation persisted; thus, the PS was deemed ineffective for B3, while no biliary dilation was found around the PSs placed in B5 and B7, so these were deemed to be effective. Marked dilation of B6 and B8 was noted, and drainage was deemed necessary . On the basis of the above findings, we planned preoperatively that an additional PS would be placed in the deep part of B3 and several other PSs would be replaced (B6 and B8). The entire ERCP procedure was performed under the combination of fluoroscopic images of a standard side-view duodenoscope (EDT-580, FUJIFILM, Tokyo, Japan) and the 3D images. This procedure was performed using a multipurpose imaging system incorporating a C-arm (VersiFlex Apla, HITACHI corporation Tokyo, Japan). During the actual ERCP procedure, endoscopists could see the endoscope video (a), the 3D image of the bile ducts that rotate freely (b), and the 2D fluoroscopic image (c) at the same time . With the 3D images for preoperative planning and intraoperative reference, biliary drainage was successfully performed without complications . Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death.", + "fulltext_subclaims": [ + "The patient was a 66-year-old man.", + "The patient underwent rectal resection and postoperative chemotherapy for rectal cancer.", + "Bile duct obstruction due to a liver metastasis caused obstructive jaundice and acute cholangitis.", + "Obstructive jaundice and acute cholangitis resulted in emergency hospitalization.", + "On magnetic resonance imaging, a 3.5 cm mass in the biliary hilum caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma.", + "Despite several attempts at biliary drainage via ERCP, obstructive jaundice was not improved.", + "The patient was emergently hospitalized again because of acute cholangitis with a 39 °C fever and epigastric pain.", + "Bile duct plastic stents had been placed in the left intrahepatic bile duct (branch of B3 and B2) and right intrahepatic bile duct (B5 and B7).", + "Repeated ERCP and biliary drainage were performed.", + "Repeated ERCP and biliary drainage had no effect as shown on the CT.", + "Many of the biliary branches were divided by the obstruction at the hilar biliary.", + "Only by 2D image, it was hard to identify the relation between dilated biliary branches and drainage tube placed.", + "Selective bile duct drainage had proven extremely difficult with the conventional procedures.", + "3D images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan).", + "3D images were used for preoperative planning.", + "Biliary drainage was performed using the 3D images as an intraoperative reference.", + "Residual dilation was observed in the left intrahepatic bile duct (B3).", + "The PS was allowing slight decompression of the left intrahepatic bile duct (B2).", + "Marked biliary dilation persisted around the PS in B3.", + "The PS was deemed ineffective for B3.", + "No biliary dilation was found around the PSs placed in B5 and B7.", + "The PSs placed in B5 and B7 were deemed to be effective.", + "Marked dilation of B6 and B8 was noted.", + "Drainage was deemed necessary for B6 and B8.", + "An additional PS would be placed in the deep part of B3.", + "Several other PSs would be replaced (B6 and B8).", + "The entire ERCP procedure was performed under the combination of fluoroscopic images of a standard side-view duodenoscope (EDT-580, FUJIFILM, Tokyo, Japan) and the 3D images.", + "The procedure was performed using a multipurpose imaging system incorporating a C-arm (VersiFlex Apla, HITACHI corporation Tokyo, Japan).", + "During the actual ERCP procedure, endoscopists could see the endoscope video, the 3D image of the bile ducts that rotate freely, and the 2D fluoroscopic image at the same time.", + "With the 3D images for preoperative planning and intraoperative reference, biliary drainage was successfully performed without complications.", + "Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death." + ], + "summary": "The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. A liver metastasis caused obstructive jaundice and acute cholangitis, necessitating emergency hospitalization. A 3.5 cm mass in the hilar region of the biliary tree caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. ERCP and biliary drainage were performed repeatedly, but had no effect. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, three-dimensional (3D) images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). Using the 3D images for preoperative planning and intraoperative reference, biliary drainage and stent placement were successfully performed without complications. Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death.", + "summary_subclaims": [ + "The patient was a 66-year-old man.", + "The patient underwent rectal resection and postoperative chemotherapy for rectal cancer.", + "A liver metastasis caused obstructive jaundice and acute cholangitis.", + "Emergency hospitalization was necessary.", + "A 3.5 cm mass in the hilar region of the biliary tree caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma.", + "ERCP and biliary drainage were performed repeatedly.", + "ERCP and biliary drainage had no effect.", + "Selective bile duct drainage had proven extremely difficult with the conventional procedures.", + "Three-dimensional images were created from preoperative CT image data using a 3D image reconstruction system.", + "The 3D images were used for preoperative planning and intraoperative reference.", + "Biliary drainage and stent placement were successfully performed without complications.", + "The patient had no further cholangitis or need for stent replacement up to his death." + ] + }, + { + "id": "multiclinsum_test_2780_en.txt", + "fulltext": "An 83-year-old male patient who underwent laparoscopic extended right hepatectomy for HCC 3 months previously presented with lung metastasis and suspicion of carcinomatous peritonitis in contrast-enhanced CT. The patient was treated with atezolizumab plus bevacizumab as first-line salvage therapy for metastatic HCC. Although the patient achieved a partial response, the lung metastasis showed progression, and bilateral hilar lymph nodes were newly detected after five cycles of the IO/TKI therapy. Thus, lenvatinib was selected as second-line salvage therapy for metastatic HCC. During the first line of IO/TKI therapy, the patient also developed gross hematuria, and contrast-enhanced abdominal CT revealed a 15 × 15 mm soft tissue mass protruding from the posterior wall of the bladder . Urine cytology yielded negative results. Cystoscopy revealed the presence of a solitary submucosal mass on the posterior wall . Based on these findings, primary bladder cancer was first suspected and surgical resection of the bladder tumor was performed.\nUnder spinal anesthesia, the patient underwent TUR-BT. The total surgical time was 26 min, and the patient was discharged from the hospital 4 days after TUR-BT without experiencing any complications. Pathological examination of the TURBT specimens showed solid and sheet-like growth of atypical epithelial cells with enlarged nuclei and prominent nucleoli in the subepithelial connective tissue and muscularis propria, similar to the histological features of HCC . Immunohistochemical staining for GATA-binding protein 3, which is typically positive in urothelial carcinoma, was negative, whereas staining for hepatocyte paraffin 1, an HCC marker, was positive . These pathological findings were consistent with a diagnosis of primary HCC with bladder metastasis . Surgical margin was negative. Four weeks after the surgery, lenvatinib was resumed. During the 2-month follow-up after the surgery, no clinical progression of lung metastasis and bilateral hilar lymph nodes was observed.", + "fulltext_subclaims": [ + "An 83-year-old male patient who underwent laparoscopic extended right hepatectomy for HCC 3 months previously presented with lung metastasis and suspicion of carcinomatous peritonitis in contrast-enhanced CT.", + "The patient was treated with atezolizumab plus bevacizumab as first-line salvage therapy for metastatic HCC.", + "The patient achieved a partial response.", + "The lung metastasis showed progression after five cycles of the IO/TKI therapy.", + "Bilateral hilar lymph nodes were newly detected after five cycles of the IO/TKI therapy.", + "Lenvatinib was selected as second-line salvage therapy for metastatic HCC.", + "During the first line of IO/TKI therapy, the patient developed gross hematuria.", + "Contrast-enhanced abdominal CT revealed a 15 × 15 mm soft tissue mass protruding from the posterior wall of the bladder.", + "Urine cytology yielded negative results.", + "Cystoscopy revealed the presence of a solitary submucosal mass on the posterior wall.", + "Based on these findings, primary bladder cancer was first suspected.", + "Surgical resection of the bladder tumor was performed.", + "Under spinal anesthesia, the patient underwent TUR-BT.", + "The total surgical time was 26 min.", + "The patient was discharged from the hospital 4 days after TUR-BT without experiencing any complications.", + "Pathological examination of the TURBT specimens showed solid and sheet-like growth of atypical epithelial cells with enlarged nuclei and prominent nucleoli in the subepithelial connective tissue and muscularis propria, similar to the histological features of HCC.", + "Immunohistochemical staining for GATA-binding protein 3 was negative.", + "Staining for hepatocyte paraffin 1 was positive.", + "These pathological findings were consistent with a diagnosis of primary HCC with bladder metastasis.", + "Surgical margin was negative.", + "Four weeks after the surgery, lenvatinib was resumed.", + "During the 2-month follow-up after the surgery, no clinical progression of lung metastasis and bilateral hilar lymph nodes was observed." + ], + "summary": "An 83-year-old man developed gross hematuria during combined treatment with an anti-programmed death-ligand 1 inhibitor and an anti-vascular endothelial growth factor for metastatic HCC. A contrast-enhanced CT revealed a 15 × 15 mm soft tissue mass protruding from the posterior bladder wall. Cystoscopy further revealed a solitary submucosal mass located on the posterior wall. The patient underwent transurethral resection of bladder tumor. The pathological findings were consistent with a diagnosis of bladder metastasis from HCC. Following a 3-week interval after the surgical intervention, salvage therapy was resumed.", + "summary_subclaims": [ + "An 83-year-old man developed gross hematuria during combined treatment with an anti-programmed death-ligand 1 inhibitor and an anti-vascular endothelial growth factor for metastatic HCC.", + "A contrast-enhanced CT revealed a 15 × 15 mm soft tissue mass protruding from the posterior bladder wall.", + "Cystoscopy further revealed a solitary submucosal mass located on the posterior wall.", + "The patient underwent transurethral resection of bladder tumor.", + "The pathological findings were consistent with a diagnosis of bladder metastasis from HCC.", + "Following a 3-week interval after the surgical intervention, salvage therapy was resumed." + ] + }, + { + "id": "multiclinsum_test_2714_en.txt", + "fulltext": "An 11-year-old Sudanese boy presented with frequent bleeding diathesis (ecchymosis, epistaxis, and gingival bleeds) . The most commonly encountered type of hemorrhage was extensive bleeding after trauma followed by subcutaneous bleeding. The patient had a history of delayed bleeding episodes since the day of circumcision, which took approximately 1 month to stop. Repeated episodes of epistaxis were also reported. He did not receive blood or blood product transfusion. He reported bleeding in the subcutaneous tissue following trauma when he was playing with his friends. Hemorrhage into joints also occurred after trauma. Spontaneous joint bleeding was not reported. Pain and slight swelling of muscles sometimes persisted for months. Looking into the family history, all family members were normal except his mother. The mother had a history of severe interval bleeding diathesis (menorrhagia). The patient had no known chronic sickness, drug allergies, or any developmental abnormality.\nOn examination, the patient was neither icteric nor cyanosed, and was not dysmorphic. There was no noticeable change when checking the ear, nose, and throat. The cardiopulmonary examination was normal. The patient’s central nervous system examination showed good sensation and reflexes. He had no skin rash or organomegaly. The liver function tests and complete blood count were all normal. Viral screening for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) were negative .\nThe coagulation tests were performed when he was asymptomatic. The main abnormal investigations were as follows: fast lysis of whole blood clots and shortened euglobulin lysis time. The other tests including clotting time, prothrombin time (PT), partial thromboplastin time (PTT), and thrombin time (TT) were all within the normal values. This suggests that there were no abnormal changes in blood coagulation. This was further confirmed by the testing of coagulation factor activity. Platelet count, bleeding time, and von Willebrand factor were also normal .\nConcerning the clot lysis test, the blood was collected and promptly placed in a glass test tube and incubated at 37°C. The clot was formed and retracted normally, but then underwent lysis. Following a few hours of incubation (5–8 hours with interval assessment), the clot was hardly visible, and it was just a small strand of fibrin. The fibrinogen and d-dimer concentration were within normal limits. To determine the status of fibrinolysis, euglobulin lysis time was calculated, and the result indicated shortened lysis time . To further investigate, we treated the patient’s plasma with a pooled normal plasma and repeated the euglobulin lysis time, which returned to normal. However, in such cases, it is preferable to use thromboelastometry to verify the diagnosis. Unfortunately, due to a lack of facilities, this technique was not performed. The defect seems to be inherited as an autosomal recessive trait .", + "fulltext_subclaims": [ + "The patient is an 11-year-old Sudanese boy.", + "The patient had frequent bleeding diathesis, including ecchymosis, epistaxis, and gingival bleeds.", + "The most commonly encountered type of hemorrhage was extensive bleeding after trauma.", + "The patient had a history of delayed bleeding episodes since the day of circumcision.", + "The bleeding after circumcision took approximately 1 month to stop.", + "Repeated episodes of epistaxis were reported.", + "The patient did not receive blood or blood product transfusion.", + "Hemorrhage into joints occurred after trauma.", + "Spontaneous joint bleeding was not reported.", + "The mother had a history of severe interval bleeding diathesis (menorrhagia).", + "The patient had no known chronic sickness, drug allergies, or any developmental abnormality.", + "The patient was neither icteric nor cyanosed.", + "The cardiopulmonary examination was normal.", + "The patient’s central nervous system examination showed good sensation and reflexes.", + "The liver function tests and complete blood count were all normal.", + "Viral screening for HIV, HBV, and HCV were negative.", + "The coagulation tests were performed when he was asymptomatic.", + "The main abnormal investigations were fast lysis of whole blood clots and shortened euglobulin lysis time.", + "The clotting time, prothrombin time (PT), partial thromboplastin time (PTT), and thrombin time (TT) were all within the normal values.", + "Platelet count, bleeding time, and von Willebrand factor were also normal.", + "The clot was formed and retracted normally but then underwent lysis.", + "The clot was hardly visible after 5–8 hours of incubation.", + "The fibrinogen and d-dimer concentration were within normal limits.", + "The euglobulin lysis time indicated shortened lysis time.", + "Treatment of the patient’s plasma with pooled normal plasma returned the euglobulin lysis time to normal.", + "It is preferable to use thromboelastometry to verify the diagnosis.", + "Thromboelastometry was not performed due to a lack of facilities.", + "The defect seems to be inherited as an autosomal recessive trait." + ], + "summary": "We report here a case of absolute deficiency of α2-AP in an 11-year-old Sudanese boy, who had a lifelong intermittent hemorrhagic tendency (gum bleeding, epistaxis, and exaggerated bleeding after trauma). Coagulation tests including prothrombin time, partial thromboplastin time, thrombin time, bleeding time, platelet count, clot retraction test, antithrombin, and factor VIII levels were within normal limits. Hepatic function tests and complete blood count were also normal. The main interesting finding in this patient was that the whole blood clot lysis was extremely fast, completed within 5-8 hours. The second abnormal finding is that the euglobulin clot lysis time was short. Nevertheless, the concentration of α2-AP in the patient's plasma was 0.2 IU/ml (reference range is 0.80-1.20 IU/ml). The addition of pooled plasma (with normal α2-AP) to the patient's whole blood corrected the accelerated fibrinolysis.", + "summary_subclaims": [ + "The patient is an 11-year-old Sudanese boy.", + "The patient had a lifelong intermittent hemorrhagic tendency.", + "The hemorrhagic tendency included gum bleeding, epistaxis, and exaggerated bleeding after trauma.", + "Coagulation tests were within normal limits.", + "The whole blood clot lysis was extremely fast, completed within 5-8 hours.", + "The euglobulin clot lysis time was short.", + "The concentration of α2-AP in the patient's plasma was 0.2 IU/ml.", + "The reference range for α2-AP is 0.80-1.20 IU/ml.", + "The addition of pooled plasma to the patient's whole blood corrected the accelerated fibrinolysis." + ] + }, + { + "id": "multiclinsum_test_1922_en.txt", + "fulltext": "A 40-year-old white Caucasian man presented to our outpatient service complaining of right hip pain. He reported having experienced this discomfort since his youth with the condition now worsening, but he denied any history of trauma. Clinical examination revealed tenderness over his right hip together with functional deficits in abduction and external rotation in his right hip joint. Conventional radiography extended by computed tomography (CT) showed a bony protuberance at the right anterior inferior iliac spine with fusion of the proximal bony nucleus to the adjacent bone . This finding together with the clinical picture was highly suggestive of a pelvic digit. Due to the patient's complaints including functional impairment in his right hip joint, surgical removal of the pelvic digit was performed and the patient was discharged 3 days later free of symptoms with a full range of motion in his right hip joint. Histopathological work-up was consistent with a rib bone .", + "fulltext_subclaims": [ + "A 40-year-old white Caucasian man presented to our outpatient service complaining of right hip pain.", + "He reported having experienced this discomfort since his youth with the condition now worsening.", + "He denied any history of trauma.", + "Clinical examination revealed tenderness over his right hip.", + "Functional deficits in abduction and external rotation in his right hip joint were noted.", + "Conventional radiography extended by computed tomography showed a bony protuberance at the right anterior inferior iliac spine.", + "The proximal bony nucleus was fused to the adjacent bone.", + "This finding together with the clinical picture was highly suggestive of a pelvic digit.", + "Surgical removal of the pelvic digit was performed.", + "The patient was discharged 3 days later free of symptoms.", + "The patient had a full range of motion in his right hip joint.", + "Histopathological work-up was consistent with a rib bone." + ], + "summary": "We present the case of a 40-year-old Caucasian man who presented with chronic pain and tenderness over his right hip together with functional impairment in abduction and external rotation. Radiology identified a bony protuberance at the right anterior inferior iliac spine with fusion of the proximal bony nucleus to the adjacent bone. The pelvic digit was surgically removed and the patient was discharged free of symptoms and with complete range of motion in his right hip joint.", + "summary_subclaims": [ + "The patient is a 40-year-old Caucasian man.", + "The patient presented with chronic pain and tenderness over his right hip.", + "The patient had functional impairment in abduction and external rotation.", + "Radiology identified a bony protuberance at the right anterior inferior iliac spine.", + "The proximal bony nucleus was fused to the adjacent bone.", + "The pelvic digit was surgically removed.", + "The patient was discharged free of symptoms.", + "The patient had complete range of motion in his right hip joint." + ] + }, + { + "id": "multiclinsum_test_516_en.txt", + "fulltext": "A 52 year-old male presented to our institution having undergone local excision of a left breast tumor one month previously. The tumor had measured 7 × 5 cm. The mass had been present for 10 years. At physical examination there was evidence of recent surgery and the patient had a 1 cm ipsilateral axillary lymph node. Serum tumor markers and other routine blood test were normal. The liver ultrasonography, chest X-ray and bone scan were negative for metastases.\nHe underwent a modified radical mastectomy. Residual tumor measuring 2.8 cm × 2.6 cm was present. On macroscopic examination the tumor was firm and circumscribed . Microscopy showed the classical features of secretory carcinoma with a microcystic pattern with abundant intra and extracellular secretory material. No tumor was present at the surgical margins. Colloidal iron staining highlighted the secretory material . On immunohistochemistry, the tumor cells were positive for S-100 protein but negative for estrogen and progesterone receptor and HER2 (Dako, Carpinteria, CA). 2 of 24 resected lymph nodes were positive for metastatic carcinoma.\nThe case was investigated for the t(12;15) ETV6-NTRK3 translocation using two complementary probe sets . A t(12;15) translocation fusion probe assay and a chromosome 15 NTRK3 gene split-apart assay were used to detect the t(12;15) translocation. All BAC clones used in this study were obtained from the BACPAC Resources Centre at the Children's Hospital Oakland Research Institute. All probes were labeled by nick translation with the use of the manufacturer's recommended protocol (Vysis, Downer's Grove, Illinois). BAC clones RP11-434C1 and RP11-407P10 telomeric to ETV6 on 12p were labeled with spectrum orange. On chromosome 15, RP11-114I9 and RP11-730G13, centromeric to NTRK3 on 15q were labeled with spectrum green and clone RP11-247E14, telomeric to NTRK3 was labeled with spectrum orange. Six-micrometer tissue sections were baked overnight at 60C and then subjected to FISH with a modified protocol (Vysis, Downers Grove, IL) . FISH signals were analyzed with a Zeiss Axioplan fluorescent microscope equipped with a COHU-CCD camera. Images were captures with Metasystems ISIS software (MetaSystems Group Inc., Belmont MA) with seven focal planes stacked for the analysis.\nIn view of the nodal metastasis it was decided to treat the patient with six courses of adjuvant 5-fluorouracil, adriamycin and cyclophosphamide (FAC). The patient abandoned treatment after the second course. The patient returned to clinic eighteen months later with two hard nodules in the surgical resection area measuring 8 × 8 cm and 4 cm × 4 cm, (one ulcerated), and three left axillary subcutaneous nodules, two measuring 2 × 2 cm and one 3 × 3 cm .\nA chest CT scan identified pulmonary metastases with a right pleural effusion . The effusion was drained via percutaneous thoracentesis. He then began treatment with concurrent radiation (total dose of 60 Gy) and UFT (Tegafur-Uracil) to the chest followed by systemic UFT as a single agent for 3 months. Post-treatment, there was no change in the pulmonary disease and there was minor response of chest-wall and axillary disease .", + "fulltext_subclaims": [ + "The patient is a 52 year-old male.", + "The patient had undergone local excision of a left breast tumor one month previously.", + "The tumor had measured 7 × 5 cm.", + "The mass had been present for 10 years.", + "At physical examination there was evidence of recent surgery.", + "The patient had a 1 cm ipsilateral axillary lymph node.", + "Serum tumor markers and other routine blood tests were normal.", + "The liver ultrasonography, chest X-ray and bone scan were negative for metastases.", + "He underwent a modified radical mastectomy.", + "Residual tumor measuring 2.8 cm × 2.6 cm was present.", + "On macroscopic examination the tumor was firm and circumscribed.", + "Microscopy showed the classical features of secretory carcinoma with a microcystic pattern with abundant intra and extracellular secretory material.", + "No tumor was present at the surgical margins.", + "Colloidal iron staining highlighted the secretory material.", + "On immunohistochemistry, the tumor cells were positive for S-100 protein.", + "On immunohistochemistry, the tumor cells were negative for estrogen and progesterone receptor.", + "On immunohistochemistry, the tumor cells were negative for HER2.", + "2 of 24 resected lymph nodes were positive for metastatic carcinoma.", + "The case was investigated for the t(12;15) ETV6-NTRK3 translocation using two complementary probe sets.", + "A t(12;15) translocation fusion probe assay was used to detect the t(12;15) translocation.", + "A chromosome 15 NTRK3 gene split-apart assay was used to detect the t(12;15) translocation.", + "All BAC clones used in this study were obtained from the BACPAC Resources Centre at the Children's Hospital Oakland Research Institute.", + "BAC clones RP11-434C1 and RP11-407P10 telomeric to ETV6 on 12p were labeled with spectrum orange.", + "On chromosome 15, RP11-114I9 and RP11-730G13, centromeric to NTRK3 on 15q were labeled with spectrum green.", + "On chromosome 15, clone RP11-247E14, telomeric to NTRK3 was labeled with spectrum orange.", + "Six-micrometer tissue sections were baked overnight at 60C.", + "FISH signals were analyzed with a Zeiss Axioplan fluorescent microscope equipped with a COHU-CCD camera.", + "Images were captured with Metasystems ISIS software.", + "In view of the nodal metastasis it was decided to treat the patient with six courses of adjuvant 5-fluorouracil, adriamycin and cyclophosphamide (FAC).", + "The patient abandoned treatment after the second course.", + "The patient returned to clinic eighteen months later with two hard nodules in the surgical resection area measuring 8 × 8 cm and 4 cm × 4 cm.", + "One of the nodules was ulcerated.", + "A chest CT scan identified pulmonary metastases with a right pleural effusion.", + "The effusion was drained via percutaneous thoracentesis.", + "He then began treatment with concurrent radiation (total dose of 60 Gy) and UFT (Tegafur-Uracil) to the chest.", + "He then began treatment with systemic UFT as a single agent for 3 months.", + "Post-treatment, there was no change in the pulmonary disease.", + "Post-treatment, there was minor response of chest-wall and axillary disease." + ], + "summary": "A 52-year-old male was diagnosed with secretory breast carcinoma and underwent a modified radical mastectomy. At 18 months the tumor recurred at the chest wall and the patient developed lung metastases. He was treated concurrently with radiation and chemotherapy without response. His tumor showed the ETV6-NTRK3 translocation as demonstrated by fluorescent in situ hybridization (FISH).", + "summary_subclaims": [ + "The patient is a 52-year-old male.", + "The patient was diagnosed with secretory breast carcinoma.", + "The patient underwent a modified radical mastectomy.", + "At 18 months the tumor recurred at the chest wall.", + "The patient developed lung metastases.", + "The patient was treated concurrently with radiation and chemotherapy.", + "The treatment with radiation and chemotherapy did not result in a response.", + "The tumor showed the ETV6-NTRK3 translocation.", + "Fluorescent in situ hybridization (FISH) demonstrated the ETV6-NTRK3 translocation." + ] + }, + { + "id": "multiclinsum_test_1081_en.txt", + "fulltext": "A 39-year-old female patient presented to our facility with a 2-day history of fevers, malaise, and central dull chest pain that was neither pleuritic nor altered by position. She had a past history of relapsing Philadelphia-positive ALL for which she had received two consecutive allogeneic stem cell transplants (SCT) from a sibling donor, as well as an infusion of donor lymphocytes. She had no previous history of cardiovascular disease and at the time of presentation had been in remission from her ALL for 6 months. Her post-remission course had been uneventful prior to her emergency presentation.\nOn assessment she was dehydrated, tachycardic (up to 130 b.p.m.) and hypotensive (90/65 mmHg) with a temperature of 38.5°C. The remainder of the cardiovascular examination was unremarkable. Blood tests demonstrated an elevated C-reactive protein of 72.7 mg/L (<10) and a Troponin T of 2490 ng/L (0–14). Her white cell count was normal (10.4 × 109/L), and peripheral blood film examination did not identify precursor cells. The remainder of her biochemistry was within normal parameters including her haemoglobin, electrolytes, creatinine, and liver function tests. Multiple blood cultures were taken and remained negative. Chest radiography was normal. Electrocardiogram (ECG) demonstrated a sinus tachycardia with new deep T-wave inversion (TWI) in leads V3–V6, not seen on a previous ECG . A transthoracic echocardiogram demonstrated mild–moderate left ventricular hypertrophy with anterior and anteroapical hypokinesis and a small circumferential pericardial effusion. The left ventricular size was normal, but systolic function was impaired with a left ventricular ejection fraction of 45%. There was no significant valvular pathology . Coronary angiography did not reveal significant obstructive disease.\nThe patient was resuscitated with IV fluids, given tazocin 4.5 g 6 hourly and commenced on therapy for presumed severe myopericarditis, receiving pulsed 1 g intravenous methylprednisolone daily for 3 days; however, failed to respond with ongoing fevers, tachycardia, and hypotension. Differential diagnoses including infiltrative, tachycardic, and catecholaminergic cardiomyopathies were considered. In the absence of a clear aetiology and given her failure to respond to initial therapy, an urgent cardiac magnetic resonance imaging (CMR) was sought. Cardiac magnetic resonance imaging identified severe, patchy increased signal intensity involving the myocardium and pericardium in the basal antero-septum, anterior wall, mid-lateral wall, and the distal interventricular septum on oedema-weighted, and late gadolinium sequences with associated regional wall motion abnormalities consistent with severe myocarditis .\nShe subsequently underwent transjugular endomyocardial biopsy (EMBx). Endomyocardial biopsy revealed a heavy infiltrate of malignant lymphocytes percolating between myocytes , with resultant atrophy of the intervening myocardial fibres as well as an accumulation of the malignant cells in a prominent perivascular and pericardial distribution , confirming a leukaemic infiltrate in the myocardium. The lymphocytes exhibited mild to moderate nuclear pleomorphism with scattered mitoses and hyperchromatic nuclei with increased N:C ratio and stained strongly positively for CD20, CD10, TdT, and PAX5 immunoperoxidase stains , confirming the presence of immature lymphoid lineage blood cells. Interphase FISH Probes for BCR/ABL1 [t(9; 22)(q34; q11.2)] revealed a signal pattern consistent with BCR-ABL1 rearrangement in the infiltrating cells and DXZ1 (X centromere), DYZ1(Yq12) loci-specific probe set confirmed that the majority of the cells contained recipient (XX) origin, with only occasional donor (XY) cells noted . These findings were in keeping with recurrence of the patient’s ALL.\nHer clinical course was complicated by runs of non-sustained ventricular tachycardia (treated with amiodarone 300 mg orally thrice daily in a weaning regimen and coupled with low-dose bisoprolol 2.5 mg daily, titrated to blood pressure), persistent fevers, and intermittent chest pain with associated changes in serum troponin. Within 2 weeks of confirmation of diagnosis by EMBx the patient had evidence of lymphoblasts (50%) in her peripheral blood. She was commenced on a second-line compassionate-access tyrosine kinase inhibitor, Ponatinib (45 mg orally once daily), as a palliative measure, though she failed to respond and by 4 weeks her blast count was 23.71 × 109/L with a doubling time of under 24 h. She soon thereafter died from fulminant multi-organ failure.", + "fulltext_subclaims": [ + "The patient was a 39-year-old female.", + "She had a 2-day history of fevers, malaise, and central dull chest pain.", + "The chest pain was neither pleuritic nor altered by position.", + "She had a past history of relapsing Philadelphia-positive ALL.", + "She had received two consecutive allogeneic stem cell transplants from a sibling donor.", + "She had received an infusion of donor lymphocytes.", + "She had no previous history of cardiovascular disease.", + "She had been in remission from her ALL for 6 months.", + "Her post-remission course had been uneventful prior to her emergency presentation.", + "On assessment, she was dehydrated.", + "She was tachycardic with a heart rate up to 130 b.p.m.", + "She was hypotensive with blood pressure 90/65 mmHg.", + "Her temperature was 38.5°C.", + "The remainder of the cardiovascular examination was unremarkable.", + "Blood tests showed an elevated C-reactive protein of 72.7 mg/L.", + "Her Troponin T was 2490 ng/L.", + "Her white cell count was 10.4 × 109/L.", + "Peripheral blood film examination did not identify precursor cells.", + "Multiple blood cultures were taken and remained negative.", + "Chest radiography was normal.", + "Electrocardiogram demonstrated a sinus tachycardia with new deep T-wave inversion in leads V3–V6.", + "A transthoracic echocardiogram demonstrated mild–moderate left ventricular hypertrophy.", + "The echocardiogram showed anterior and anteroapical hypokinesis.", + "The echocardiogram showed a small circumferential pericardial effusion.", + "The left ventricular ejection fraction was 45%.", + "Coronary angiography did not reveal significant obstructive disease.", + "The patient was resuscitated with IV fluids.", + "She was given tazocin 4.5 g 6 hourly.", + "She was commenced on therapy for presumed severe myopericarditis.", + "She received pulsed 1 g intravenous methylprednisolone daily for 3 days.", + "She failed to respond with ongoing fevers, tachycardia, and hypotension.", + "Differential diagnoses included infiltrative, tachycardic, and catecholaminergic cardiomyopathies.", + "An urgent cardiac magnetic resonance imaging was sought.", + "Cardiac magnetic resonance imaging identified severe, patchy increased signal intensity involving the myocardium and pericardium.", + "The signal intensity was in the basal antero-septum, anterior wall, mid-lateral wall, and the distal interventricular septum.", + "The findings were consistent with severe myocarditis.", + "She underwent transjugular endomyocardial biopsy.", + "Endomyocardial biopsy revealed a heavy infiltrate of malignant lymphocytes percolating between myocytes.", + "The lymphocytes caused atrophy of the intervening myocardial fibres.", + "There was an accumulation of the malignant cells in a prominent perivascular and pericardial distribution.", + "The findings confirmed a leukaemic infiltrate in the myocardium.", + "The lymphocytes exhibited mild to moderate nuclear pleomorphism.", + "The lymphocytes showed scattered mitoses and hyperchromatic nuclei with increased N:C ratio.", + "The lymphocytes stained strongly positively for CD20, CD10, TdT, and PAX5 immunoperoxidase stains.", + "Interphase FISH Probes for BCR/ABL1 revealed a signal pattern consistent with BCR-ABL1 rearrangement in the infiltrating cells.", + "DXZ1 and DYZ1 loci-specific probe sets confirmed that the majority of the cells contained recipient (XX) origin.", + "Only occasional donor (XY) cells were noted.", + "These findings were in keeping with recurrence of the patient’s ALL.", + "She had runs of non-sustained ventricular tachycardia.", + "She was treated with amiodarone 300 mg orally thrice daily in a weaning regimen.", + "She was given low-dose bisoprolol 2.5 mg daily, titrated to blood pressure.", + "Within 2 weeks of diagnosis confirmation, she had evidence of lymphoblasts (50%) in her peripheral blood.", + "She was commenced on a second-line compassionate-access tyrosine kinase inhibitor, Ponatinib 45 mg orally once daily.", + "She failed to respond to Ponatinib.", + "By 4 weeks, her blast count was 23.71 × 109/L with a doubling time of under 24 h.", + "She soon thereafter died from fulminant multi-organ failure." + ], + "summary": "Here, we present an unusual case of isolated gross intracardiac relapse of ALL in a patient presenting with chest pain and fevers. Both cardiac magnetic resonance imaging and endomyocardial biopsy were utilized in the diagnosis and identified leukaemic infiltrate in the absence of peripheral lymphoblasts.", + "summary_subclaims": [ + "This is an unusual case of isolated gross intracardiac relapse of ALL.", + "The patient presented with chest pain and fevers.", + "Cardiac magnetic resonance imaging was utilized in the diagnosis.", + "Endomyocardial biopsy was utilized in the diagnosis.", + "Leukaemic infiltrate was identified.", + "Peripheral lymphoblasts were absent." + ] + }, + { + "id": "multiclinsum_test_23_en.txt", + "fulltext": "This is a case of a 50 years old female patient who is known to be hypertensive, dyslipidemic, obese (BMI: 31.88-Height: 168 cm Weight: 90 kg), and operated of sleeve gastrectomy in 2012.\nOn the morning of 13/02/2013, the patient noted a near syncope episode. She was transferred to the emergency department for a fever of 39.2°C, a microcytic anemia (Hb: 7 g/dl) with elevated inflammatory markers CRP 239 mg/l and ESR 90 mm and admitted for care and investigation.\nHer physical exam showed lower limbs weakness at 4/5 proximally and distally (possible movement against gravity with moderate resistance). She was put on IV meropenem after blood and urine cultures were taken. The gram color was negative so were the cultures after 48 hours.\nOn the following morning she started complaining of paraparesia. Her physical examination showed a motor deficit of the lower limbs at 1/5 (visible contraction without any movement) with total anesthesia in all modalities (proprioceptive and thermo-algic). A D6 level was also noted.\nAn abdomino-pelvic computer tomography (CT) scan showed a complete thrombosis in the lower part of the mesenteric and the splenic veins extending to the portal bifurcation and the intrahepatic portal branches. It associated an important infiltration of the peritoneal and peri-pancreatic fat, and a mean abundance of free peri-hepatic, splenic and peri-pelvic ascites. There was a collection of 42 × 15 mm near the splenic hilum, containing a trace of contrast and a small two-fluid level. This collection seemed to communicate with the digestive tract at the gastro-esophago-jejunal anastomosis in its proximal part, suggestive of infected fistula .\nIV heparin was added to her medications.\nAn urgent brain and cervico-dorso-lombar MRI (magnetic resonance imaging) were performed and showed:Small brain abscesses formation Figure . An extensive transverse infectious myelitis Figure .\nIn front of these findings a lumbar puncture was performed revealing 430 WBC (92% neutrophils, 7% lymphocytes, and 1% mesothelial cells) 10 RBC with hypoglycorachia and hyperproteinorachia in favor of an inflammatory liquid with polymorphic predominance of polynucleated elements. The objective of this technique was to try to isolate a bacterium. The CSF culture returned sterile and PCR BK was negative.\nAn electromyogram was normal.\nAfter this result vancomycin was added to the treatment regimen.\nClinical presentation, physical examination, and history are important diagnostic tools in assessing an acute myelopathy as the pattern of functional loss can help to determine the location of the lesion. When an acute myelopathy is suspected, a thorough neurological evaluation will help determine the region of the spinal cord affected and then the next diagnostic step is to evaluate for a compressive or structural etiology (Timothy W. ).\nMagnetic resonance imaging (MRI) of the complete spinal axis is mandatory in any patient with myelopathic features to exclude structural lesions, particularly those amenable to emergent neurosurgical intervention .\nOnce neuroimaging has excluded a compressive etiology, a lumbar puncture (LP) is indicated to determine if there are signs of inflammation within the cerebrospinal fluid (CSF). If the CSF is non-inflammatory, then vascular, toxic/metabolic, neurodegenerative, or neoplastic myelopathies become much more likely and the subsequent work-up should focus on these etiologies. If the CSF shows signs of inflammation (pleocytosis, elevated protein concentration, oligoclonal bands, or elevated IgG index), then the subsequent work-up should focus on demyelinating, infectious, or other inflammatory causes of an acute myelitis, as the differential diagnosis is broad .\nHowever, for elucidating the etiology of infectious myelitis, CSF studies are essential. CSF studies include cell count with differential protein and glucose concentrations. In addition, measurements of intrathecal immunoglobulin production with oligoclonal bands (OCBs) and an immunoglobulin G index or synthesis rate are very helpful when trying to determine the presence and etiology of myelitis.\nAn elevated protein concentration is the most common CSF abnormality in patients with spinal cord disease and is present in approximately 50% of patients with transverse myelitis . A low CSF glucose concentration is defined as less than 60% of serum glucose and generally suggests fungal, bacterial, or mycobacterial infection, especially when associated with an elevated CSF white blood cell count. An isolated low CSF glucose concentration can occur in neurosarcoidosis, leptomeningeal carcinomatosis, subarachnoid hemorrhage, and even systemic lupus erythematosus (SLE) with CNS involvement . The white blood cell differential can be very helpful as well. The presence of eosinophils can suggest parasitic or fungal infection, the presence of foreign material (such as surgical hardware following a spinal operation) or possibly neuromyelitis optica (NMO) (Timothy W. ).\nThe most frequent pathogens involved in transverse myelitis include Treponema palidum, Mycobacerium tuberculosis, Borrelia burgdorferi, Campylobacter jejuni, Acinetobacter baumanii, Coxiella burnetii, Bartonella henselae, Chlamydia psittaci, Leprospira, Chlamydia pneunoniae, Legionella pneumonia, Orientia tsutsugamushi (scrub typhus), Salmonella paratyphi B, Brucellosis melitensis, Group A and B streptococci .\nIntramedullary abscess may also complicate congenital dermal sinuses or bacterial endocarditis. So a cardiac echography should be performed to exclude endocarditis.\nIn our case, a PPD, HIV serology, wright and widal all returned negative. A cardiac echography was performed and ruled out any sign for endocarditis.\nSuccessful treatment of infections of the nervous system depends on rapid and accurate diagnosis. The time course of symptom progression may suggest specific pathogens. In general, symptoms of less than 2 day’s duration bespeak bacterial processes. The clinical syndrome and associated extra neural infection sites favor certain organisms .\nEmpiric corticosteroids may be of benefit in bacterial and in tuberculous meningitis . For bacterial meningitis, the typical dosing is a four-day regimen of dexamethasone (0.6 mg/kg daily) started before or with the first dose of antibiotics .\nOur patient had developed an abdominal abscess with fistula. The bacteria implicated in her myelitis are probably an enterobacteriaceae or an enterococcus. The CSF culture was negative probably because we already initiated the meropenem before the lumbar puncture was performed.\nA follow-up brain and cervico-dorsal MRI after 2 months of IV treatment (IV meropenem and vancomycine) showed: Figure .Net decrease of small contrast enhancing lesions scattered with persistence of nodular contrast right frontobasal, left upper front, in the region of the left and right thalamic lenticular ventricular junction, compared with small abscess formations in the process healing. We found a great reduction in the T2 signal abnormalities of the spinal, cervical, and thoracolumbar intramedullary spine signal. Virtual disappearance of intramedullary signal abnormality in the cervical spinal and back to a normal size.\n1 year after the myelitis and physical rehabilitation, her physical exam shows motility at 3/5 (active movement against gravity) over both her lower limbs. The sensitivity over her lower limbs is recovering but poorly over the feet. Her sphincteral dysfunction is still persistent.\nThe differential diagnosis with the infectious myelitis is one caused by autoimmune disease. A thorough workup was conducted eliminating all autoimmune diseases. The antinuclear antibodies, antibodies to extractable nuclear antigen, rheumatoid factor, antiphospholipid antibodies, and anti-neutrophil cytoplasmic antibodies (ANCA) are all negative .\nCSF and blood angiotensin-converting enzyme levels are normal.", + "fulltext_subclaims": [ + "The patient is a 50-year-old female.", + "The patient is known to be hypertensive.", + "The patient is known to be dyslipidemic.", + "The patient is obese with a BMI of 31.88.", + "The patient had sleeve gastrectomy in 2012.", + "On 13/02/2013, the patient noted a near syncope episode.", + "The patient was transferred to the emergency department for a fever of 39.2°C.", + "The patient had microcytic anemia with hemoglobin of 7 g/dl.", + "The patient had elevated CRP of 239 mg/l.", + "The patient had elevated ESR of 90 mm.", + "The patient was admitted for care and investigation.", + "The patient's physical exam showed lower limbs weakness at 4/5 proximally and distally.", + "The patient was put on IV meropenem after blood and urine cultures were taken.", + "Gram stain was negative.", + "Blood and urine cultures were negative after 48 hours.", + "On the following morning, the patient started complaining of paraparesia.", + "The patient's physical examination showed a motor deficit of the lower limbs at 1/5.", + "The patient had total anesthesia in all modalities.", + "A D6 level was noted.", + "An abdomino-pelvic CT scan showed complete thrombosis in the lower part of the mesenteric and splenic veins.", + "The CT scan showed extension to the portal bifurcation and intrahepatic portal branches.", + "The CT scan showed important infiltration of the peritoneal and peri-pancreatic fat.", + "The CT scan showed a mean abundance of free peri-hepatic, splenic, and peri-pelvic ascites.", + "The CT scan showed a collection of 42 × 15 mm near the splenic hilum.", + "The collection contained a trace of contrast and a small two-fluid level.", + "The collection seemed to communicate with the digestive tract at the gastro-esophago-jejunal anastomosis.", + "The collection was suggestive of infected fistula.", + "IV heparin was added to her medications.", + "An urgent brain and cervico-dorso-lombar MRI was performed.", + "The MRI showed small brain abscesses formation.", + "The MRI showed extensive transverse infectious myelitis.", + "A lumbar puncture was performed.", + "The CSF showed 430 WBC with 92% neutrophils.", + "The CSF showed 7% lymphocytes and 1% mesothelial cells.", + "The CSF showed 10 RBC.", + "The CSF showed hypoglycorachia and hyperproteinorachia.", + "The CSF culture returned sterile.", + "The CSF PCR BK was negative.", + "An electromyogram was normal.", + "Vancomycin was added to the treatment regimen.", + "Clinical presentation, physical examination, and history are important diagnostic tools in assessing an acute myelopathy.", + "A thorough neurological evaluation will help determine the region of the spinal cord affected.", + "MRI of the complete spinal axis is mandatory in any patient with myelopathic features.", + "A lumbar puncture is indicated to determine if there are signs of inflammation within the CSF.", + "CSF studies are essential for elucidating the etiology of infectious myelitis.", + "An elevated protein concentration is the most common CSF abnormality in patients with spinal cord disease.", + "A low CSF glucose concentration generally suggests fungal, bacterial, or mycobacterial infection.", + "The most frequent pathogens involved in transverse myelitis include Treponema palidum, Mycobacterium tuberculosis, Borrelia burgdorferi, Campylobacter jejuni, Acinetobacter baumanii, Coxiella burnetii, Bartonella henselae, Chlamydia psittaci, Leprospira, Chlamydia pneumoniae, Legionella pneumonia, Orientia tsutsugamushi, Salmonella paratyphi B, Brucellosis melitensis, Group A and B streptococci.", + "A cardiac echography should be performed to exclude endocarditis.", + "In our case, a PPD, HIV serology, wright and widal all returned negative.", + "A cardiac echography was performed and ruled out any sign for endocarditis.", + "The bacteria implicated in her myelitis are probably an enterobacteriaceae or an enterococcus.", + "The CSF culture was negative probably because we already initiated the meropenem before the lumbar puncture was performed.", + "A follow-up brain and cervico-dorsal MRI after 2 months of IV treatment showed a net decrease of small contrast enhancing lesions.", + "The MRI showed persistence of nodular contrast right frontobasal, left upper front, in the region of the left and right thalamic lenticular ventricular junction.", + "The MRI showed a great reduction in the T2 signal abnormalities of the spinal, cervical, and thoracolumbar intramedullary spine signal.", + "The MRI showed virtual disappearance of intramedullary signal abnormality in the cervical spinal and back to a normal size.", + "1 year after the myelitis and physical rehabilitation, her physical exam shows motility at 3/5 over both her lower limbs.", + "The sensitivity over her lower limbs is recovering but poorly over the feet.", + "Her sphincteral dysfunction is still persistent.", + "A thorough workup was conducted eliminating all autoimmune diseases.", + "The antinuclear antibodies, antibodies to extractable nuclear antigen, rheumatoid factor, antiphospholipid antibodies, and anti-neutrophil cytoplasmic antibodies (ANCA) are all negative.", + "CSF and blood angiotensin-converting enzyme levels are normal." + ], + "summary": "This is the case of a 55 years old female patient who develops sudden onset abdominal abscess one year after bariatric surgery that was complicated by an extensive infectious myelitis and cerebral abscesses without any cerebral symptoms. She received adequate antibiotherapy treatment with good evolution.", + "summary_subclaims": [ + "This is the case of a 55 years old female patient.", + "She develops sudden onset abdominal abscess.", + "The abdominal abscess occurred one year after bariatric surgery.", + "The bariatric surgery was complicated by an extensive infectious myelitis.", + "The bariatric surgery was complicated by cerebral abscesses.", + "There were no cerebral symptoms.", + "She received adequate antibiotherapy treatment.", + "She had good evolution." + ] + }, + { + "id": "multiclinsum_test_355_en.txt", + "fulltext": "A 39- years old multiparous woman has suffered from mild MS for 10 years, as a result of childhood bacterial tonsilopharyngitis (rheumatic MS). The first attacks of symptoms appeared in her last year of second decade, during her second pregnancy. Her chief complaint was exertional dyspnea. Two - dimensional echocardiography (2D-ECG) revealed a decreased mitral valve area (1.5 cm2). She had no other medical conditions and her past medical history included nothing else of note. Recently the symptoms worsened and she began to experience dyspnea in ordinary activities, AF and hemoptesia (hemoptysis). 2D-ECG positive findings were: critical diminished mitral valve area (0.8 cm2), left atrial enlargement without any organized clot attachment, thickened leaflets, commissural and subvalvular fussions and mean diastolic pressure gradient across valve =12 mmHg. She was scheduled for MVR with mechanical prosthesis. Open cardiac surgery with CPB using bicaval connulation was carried out. Early post-operative course was uneventful and she was discharged to home on POD = 7 with warfarin prescription without any prohibition about taking it, since she had completed her family members. She felt face tenderness and hearing problems besides stuffy and clogged nose on POD = 20. She underwent ENT consultation and based on the clinical and paraclinical finding, met ARS diagnosis . As soon as an antihistamine, anticongestion and macrolide antibiotic was initiated. She came back to ENT service with persistent ARS as well as relapsing preoperative couphs and dyspnea besides lower extremities edema and toenails discoloration . After some modulations of therapeutic drugs, she was referred to pulmonary clinic on POD = 30. CXR confirmed a significant left pleural effusion and she was readmitted in our service while taking lasix and SABAs (albuterol inhaler) in addition to aforementioned medicines on POD = 33. Immediately a pigtail catheter was secured with the purpose of both assessment and management. At first the fluid was bloody then became milky. Finally we attained 1850 cc frankly white fluid. Bedside ether test revealed the presence of fat which was confirmed by lab study (triglycerides = 1750 mg/dl chylomicron). We encountered with a patient who had different signs such as chylothorax, lymphedema and yellow discoloration of toenails. After dermatologist consultation we arrived at Yellow Nail Syndrome on POD = 35. Immediately conservative treatment was taken place such as bed rest, massage and compression therapy of legs using garments, restricted diet consist of high protein low fat with medium chain triglycerides and octreotide. Since the decline of chylous drainage was unsatisfied (330 cc/d), we exchanged the pigtail catheter with an appropriate size chest tube and TPN was initiated. Then talc and doxycycline pleurodesis was carried out besides Vitamine E supplement on POD = 41. Fortunately chest tube output substantially decreased, allowing transition to low fat oral intake diet on POD =45. Chest tube was removed and the patient was discharged on POD = 47. At 4 weeks follow ups, CXR was clear without effusion and nails discoloration and legs lymphedema resolved.", + "fulltext_subclaims": [ + "The patient is a 39-year-old multiparous woman.", + "She has suffered from mild mitral stenosis for 10 years.", + "The mitral stenosis resulted from childhood bacterial tonsilopharyngitis.", + "The first attacks of symptoms appeared in her last year of second decade.", + "The first attacks occurred during her second pregnancy.", + "Her chief complaint was exertional dyspnea.", + "Two-dimensional echocardiography revealed a decreased mitral valve area of 1.5 cm2.", + "She had no other medical conditions.", + "Her past medical history included nothing else of note.", + "Recently, the symptoms worsened.", + "She began to experience dyspnea in ordinary activities.", + "She had atrial fibrillation.", + "She had hemoptysis.", + "Two-dimensional echocardiography showed a critical diminished mitral valve area of 0.8 cm2.", + "There was left atrial enlargement without any organized clot attachment.", + "The leaflets were thickened.", + "There were commissural and subvalvular fusions.", + "The mean diastolic pressure gradient across the valve was 12 mmHg.", + "She was scheduled for mitral valve replacement with a mechanical prosthesis.", + "Open cardiac surgery with cardiopulmonary bypass using bicaval cannulation was carried out.", + "The early post-operative course was uneventful.", + "She was discharged to home on post-operative day 7.", + "She was prescribed warfarin.", + "There was no prohibition about taking warfarin.", + "She felt face tenderness and hearing problems on post-operative day 20.", + "She had a stuffy and clogged nose on post-operative day 20.", + "She underwent an ENT consultation.", + "Based on clinical and paraclinical findings, she was diagnosed with acute rhinosinusitis.", + "An antihistamine, an anticongestion medication, and a macrolide antibiotic were initiated.", + "She returned to the ENT service with persistent acute rhinosinusitis.", + "She had relapsing preoperative cough and dyspnea.", + "She had lower extremity edema.", + "She had toenail discoloration.", + "After some modifications of therapeutic drugs, she was referred to pulmonary clinic on post-operative day 30.", + "Chest X-ray confirmed a significant left pleural effusion.", + "She was readmitted on post-operative day 33.", + "A pigtail catheter was secured with the purpose of both assessment and management.", + "The fluid was initially bloody then became milky.", + "A total of 1850 cc of frankly white fluid was obtained.", + "The bedside ether test revealed the presence of fat.", + "The fluid was confirmed to be chylous by lab study (triglycerides = 1750 mg/dl chylomicron).", + "The patient had signs such as chylothorax, lymphedema, and yellow discoloration of toenails.", + "After dermatologist consultation, Yellow Nail Syndrome was diagnosed on post-operative day 35.", + "Conservative treatment included bed rest, massage, and compression therapy of legs using garments.", + "The diet was restricted to high protein, low fat with medium chain triglycerides.", + "Octreotide was initiated.", + "The decline of chylous drainage was unsatisfactory (330 cc/day).", + "The pigtail catheter was exchanged with an appropriate size chest tube.", + "Total parenteral nutrition was initiated.", + "Talc and doxycycline pleurodesis was carried out.", + "Vitamin E supplement was started.", + "Chest tube output substantially decreased.", + "Transition to low fat oral intake diet was allowed.", + "The chest tube was removed.", + "The patient was discharged on post-operative day 47.", + "At 4 weeks follow-up, chest X-ray was clear without effusion.", + "Nail discoloration resolved.", + "Leg lymphedema resolved." + ], + "summary": "Twenty days after mitral valve replacement for severe rheumatic mitral valve stenosis, 39 years old woman presented with face tenderness and hearing problems besides stuffy and clogged nose and underwent routin rhinosinusitis therapy. She came back to ears, nose and throat service with persistent rhinosinusitis as well as relapsing preoperative couphs and dyspnea besides lower extremities edema and toenails discoloration. After some modulations of treatment, she was introduced to pulmonary clinic on post -operative day = 30. Chest x ray showed a lot of left pleural effusion then she was returned to our service (cardiac surgery) on post- operative day = 33. The pigtail catheter was secured and we attained a significant amount of milky fluid which conformed with chylothorax. Finally Yellow nail syndrome was diagnosed with her on post-operative day = 35. Early conservative therapy such as bed rest, legs massage, low fat diet with medium chain triglycerides, diuretics, bronchodilator inhaler was not be able to satisfy us (chylous out put > 330 cc/d). Therefore the catheter replacement with chest tube was carried out followed by pleurodesis using Talc and doxycycline besides transition of oral intake to total parentral nutrition and vitamine E supplement, on post - operative day = 41. After that chylous leakage gradually subsided and patient was discharged to home on post- operative day = 47. At 4 weeks follow ups, chest x ray was clear without effusion and nails discoloration and legs lymphedema resolved.", + "summary_subclaims": [ + "The patient was a 39-year-old woman.", + "She had mitral valve replacement for severe rheumatic mitral valve stenosis.", + "Twenty days after surgery, she presented with face tenderness and hearing problems.", + "She had a stuffy and clogged nose.", + "She underwent routine rhinosinusitis therapy.", + "She returned to the ears, nose, and throat service with persistent rhinosinusitis.", + "She had relapsing preoperative cough and dyspnea.", + "She had lower extremity edema.", + "She had toenail discoloration.", + "She was introduced to the pulmonary clinic on post-operative day 30.", + "Chest x-ray showed a lot of left pleural effusion.", + "She was returned to the cardiac surgery service on post-operative day 33.", + "A pigtail catheter was secured.", + "A significant amount of milky fluid was attained.", + "The fluid conformed with chylothorax.", + "Yellow nail syndrome was diagnosed on post-operative day 35.", + "Early conservative therapy included bed rest, leg massage, low-fat diet with medium chain triglycerides, diuretics, and bronchodilator inhaler.", + "The chylous output was greater than 330 cc per day.", + "The catheter was replaced with a chest tube on post-operative day 41.", + "Pleurodesis was performed using Talc and doxycycline.", + "Oral intake was transitioned to total parenteral nutrition.", + "Vitamin E supplement was provided.", + "Chylous leakage gradually subsided.", + "The patient was discharged to home on post-operative day 47.", + "At 4 weeks follow-up, chest x-ray was clear without effusion.", + "Nail discoloration resolved.", + "Leg lymphedema resolved." + ] + }, + { + "id": "multiclinsum_test_2322_en.txt", + "fulltext": "A 52-year-old gentleman had presented to the emergency room with sudden onset left hemiparesis, with a Glasgow Coma Scale (GCS) of E2M5Vt. He was diagnosed with a 210 mL volume, middle cerebral artery (MCA) territory infarction on magnetic resonance (MR) imaging with mass effect and a 12 mm midline shift. He was also diagnosed with a right brachial artery embolus on routine large vessel and neck MR angiograms. Carotid vasculature was noted to be normal with no narrowing or filling defect. An emergency right fronto-temporo-parietal decompressive with lax duraplasty was performed followed by a right brachial embolectomy by the vascular team. Further evaluation with a cardiac 2D echogram revealed no regional wall motion abnormality with mild concentric left ventricular hypertrophy (LVH), normally functioning valves and no clots or vegetations. Postoperatively, he had an uneventful recovery and over a week GCS improved to E4M6V5. He was discharged on therapeutic doses of low molecular weight heparin for the brachial artery embolus.\nHe presented 6 months later for a cranioplasty. He was conscious alert and oriented with modified Ashworth Grade II hypertonia and Medical Research Council Grade 3 power in the left upper and lower limbs. A computed tomography (CT) scan revealed a sunken skin flap with a 9 mm midline shift to the left along with gliotic changes in the right MCA territory . The autologous bone preserved in a freezer was found to be unhealthy and he underwent a customized titanium mold cranioplasty. Intraoperatively, the brain was sunken. Urine output was maintained at 80–150 mL/h and vitals were stable with minimal fluctuations. The surgery was completed uneventfully.\nThe patient did not wake from anesthesia and had sudden fall in blood pressure (BP) to 60/40 mmHg a few minutes after shifting, on ventilator, to the intensive care unit. The hypotension lasted for less than a minute and he was stabilized with inotropes and noradrenaline boluses and later a drip infusion, with close titration owing to a very labile BP highly sensitive to minor adjustments in the inotropes. Blood gases, electrolytes, and postoperative hematocrit were within normal limits. A screening echocardiogram at the time showed an ejection fraction of 55% with freely moving valves and no clots or vegetations, ruling out a cardiac cause for the hypotension. During and immediately following stabilization, his pupils began dilating bilaterally from 2 mm to 8 mm over 30 min.\nA CT scan showed diffuse severe cerebral edema in bilateral hemispheres with effaced basal cisterns, microhemorrhages, and expansion of the sunken right gliotic brain along with ipsilateral ventricular dilatation. There was poor grey-white matter differentiation in the contralateral (left) side with a midline shift of 5 mm toward the right (cranioplasty) side . GCS remained E1M1Vt (No eye response or motor response, intubated on ventilator support) and pupils was now dilated fixed (8 mm bilaterally). Due to left-sided edema and risk of aggravation of midline shift by the right-sided titanium mold removal, a left-sided decompressive craniectomy and lax duraplasty were deemed suitable and performed.\nA magnetic resonance imaging was performed the subsequent day that showed bilateral posterior cerebral artery territory and brainstem infarcts .\nDespite all possible efforts and interventions, the patient did not improve, had absent brainstem signs with dilated fixed pupils and a GCS of E1M1Vt, and eventually a fatal outcome.\nIn this case, other possibilities of malignant cerebral edema include fresh emboli from the heart causing fresh infarcts. Although fresh infarcts developing severe edema rapidly within an hour is rare, a screening cardiac 2D echogram was done at the time which showed normal findings apart from mild concentric LVH, and an ejection fraction of 55%, matching the evaluation done at the time of the initial infarct.\nHypoxia during surgery could theoretically cause bihemispheric edema; however, no such hypoxia or desaturation occurred intraoperatively or immediately postoperatively.\nHypotension due to an unrelated cause and subsequent hypoxic brain injury leading to malignant edema may be considered. However, no other systemic causes of hypotension could be identified. There was minimal blood loss during surgery and an 80–150 mL/h urine output throughout ruling out hypovolemia. Cardiac causes had been ruled out (as mentioned earlier) and there was no cause for septic shock immediate postoperatively. It was hence concluded that the hypotension was a consequence of severe brain edema and loss of autonomic control, further supported by the lability of the BP and extreme sensitivity to inotropic agents.\nAfter excluding the above, the sequence of events suggests postcranioplasty malignant edema due to a change in pressure dynamics, as the most likely cause of the deterioration.", + "fulltext_subclaims": [ + "The patient was a 52-year-old gentleman.", + "He had sudden onset left hemiparesis.", + "His Glasgow Coma Scale (GCS) was E2M5Vt.", + "He was diagnosed with a 210 mL volume, middle cerebral artery (MCA) territory infarction on magnetic resonance (MR) imaging.", + "The infarction had mass effect and a 12 mm midline shift.", + "He was diagnosed with a right brachial artery embolus on routine large vessel and neck MR angiograms.", + "Carotid vasculature was noted to be normal with no narrowing or filling defect.", + "An emergency right fronto-temporo-parietal decompressive with lax duraplasty was performed.", + "A right brachial embolectomy was performed by the vascular team.", + "A cardiac 2D echogram revealed no regional wall motion abnormality.", + "The echogram showed mild concentric left ventricular hypertrophy (LVH).", + "The echogram showed normally functioning valves.", + "The echogram showed no clots or vegetations.", + "Postoperatively, he had an uneventful recovery.", + "Over a week, his GCS improved to E4M6V5.", + "He was discharged on therapeutic doses of low molecular weight heparin for the brachial artery embolus.", + "He presented 6 months later for a cranioplasty.", + "He was conscious, alert, and oriented.", + "He had modified Ashworth Grade II hypertonia.", + "He had Medical Research Council Grade 3 power in the left upper and lower limbs.", + "A computed tomography (CT) scan revealed a sunken skin flap.", + "The CT scan showed a 9 mm midline shift to the left.", + "The CT scan showed gliotic changes in the right MCA territory.", + "The autologous bone preserved in a freezer was found to be unhealthy.", + "He underwent a customized titanium mold cranioplasty.", + "Intraoperatively, the brain was sunken.", + "Urine output was maintained at 80–150 mL/h.", + "Vitals were stable with minimal fluctuations.", + "The surgery was completed uneventfully.", + "The patient did not wake from anesthesia.", + "He had a sudden fall in blood pressure (BP) to 60/40 mmHg a few minutes after shifting, on ventilator, to the intensive care unit.", + "The hypotension lasted for less than a minute.", + "He was stabilized with inotropes and noradrenaline boluses.", + "Later, a noradrenaline drip infusion was started with close titration.", + "Blood gases, electrolytes, and postoperative hematocrit were within normal limits.", + "A screening echocardiogram showed an ejection fraction of 55%.", + "The echocardiogram showed freely moving valves.", + "The echocardiogram showed no clots or vegetations.", + "During and immediately following stabilization, his pupils began dilating bilaterally from 2 mm to 8 mm over 30 min.", + "A CT scan showed diffuse severe cerebral edema in bilateral hemispheres.", + "The CT scan showed effaced basal cisterns.", + "The CT scan showed microhemorrhages.", + "The CT scan showed expansion of the sunken right gliotic brain.", + "The CT scan showed ipsilateral ventricular dilatation.", + "There was poor grey-white matter differentiation in the contralateral (left) side.", + "There was a midline shift of 5 mm toward the right (cranioplasty) side.", + "GCS remained E1M1Vt.", + "Pupils were now dilated fixed (8 mm bilaterally).", + "A left-sided decompressive craniectomy and lax duraplasty were deemed suitable.", + "A magnetic resonance imaging was performed the subsequent day.", + "The MRI showed bilateral posterior cerebral artery territory infarcts.", + "The MRI showed brainstem infarcts.", + "The patient did not improve.", + "He had absent brainstem signs.", + "He had dilated fixed pupils.", + "He had a GCS of E1M1Vt.", + "He eventually had a fatal outcome.", + "Other possibilities of malignant cerebral edema include fresh emboli from the heart causing fresh infarcts.", + "Fresh infarcts developing severe edema rapidly within an hour is rare.", + "A screening cardiac 2D echogram was done at the time.", + "The echogram showed normal findings apart from mild concentric LVH.", + "The echogram showed an ejection fraction of 55%.", + "Hypoxia during surgery could theoretically cause bihemispheric edema.", + "No such hypoxia or desaturation occurred intraoperatively or immediately postoperatively.", + "Hypotension due to an unrelated cause and subsequent hypoxic brain injury leading to malignant edema may be considered.", + "No other systemic causes of hypotension could be identified.", + "There was minimal blood loss during surgery.", + "An 80–150 mL/h urine output throughout ruled out hypovolemia.", + "Cardiac causes had been ruled out.", + "There was no cause for septic shock immediate postoperatively.", + "It was hence concluded that the hypotension was a consequence of severe brain edema and loss of autonomic control.", + "The sequence of events suggests postcranioplasty malignant edema due to a change in pressure dynamics, as the most likely cause of the deterioration." + ], + "summary": "A 52-year-old gentleman with a 210 mL volume and middle cerebral artery territory infarction underwent an emergency craniectomy and 6 months later a titanium mold cranioplasty. Precranioplasty computed tomography (CT) scan evaluation revealed a sunken skin flap with a 9 mm contralateral midline shift. Immediately following an uneventful surgery, the patient had sudden fall in blood pressure to 60/40 mmHg and over a few min had dilated fixed pupils. CT revealed severe diffuse cerebral edema in bilateral hemispheres with microhemorrhages and expansion of the sunken right gliotic brain along with ipsilateral ventricular dilatation. Despite undergoing a contralateral decompressive craniectomy due to the midline shift toward the right, the outcome was fatal.", + "summary_subclaims": [ + "The patient is a 52-year-old gentleman.", + "The patient had a 210 mL volume middle cerebral artery territory infarction.", + "The patient underwent an emergency craniectomy.", + "The patient had a titanium mold cranioplasty 6 months later.", + "Precranioplasty CT scan showed a sunken skin flap.", + "Precranioplasty CT scan showed a 9 mm contralateral midline shift.", + "The patient had sudden fall in blood pressure to 60/40 mmHg immediately following surgery.", + "The patient had dilated fixed pupils over a few minutes.", + "CT revealed severe diffuse cerebral edema in bilateral hemispheres.", + "CT showed microhemorrhages.", + "CT showed expansion of the sunken right gliotic brain.", + "CT showed ipsilateral ventricular dilatation.", + "The patient underwent a contralateral decompressive craniectomy.", + "The outcome was fatal." + ] + }, + { + "id": "multiclinsum_test_3197_en.txt", + "fulltext": "The case of a 65-year-old man with a history of hypertension and smoking was admitted from another institution with a diagnosis of acute abdomen, reporting a picture of approximately 48 hours of pain in the lower abdominal area that did not subside with common analgesics, associated with nausea. On admission, he presented a positive Blumberg sign, for which a study was completed with a blood count, showing a leukocytosis of 18,320 mm³ and neutrophilia of 85%. A computed tomography (CT) of the abdomen with intravenous contrast was performed, showing a saccular image of 52 x 41 mm, dependent on the loop of the terminal ileum, with a pattern of bread crumbs, which presented peripheral enhancement, rarefaction of adjacent fat and at the root of the mesentery, findings that were related to Meckel's diverticulitis, also observing pneumoperitoneum and free liquid in the abdominal cavity, for which signs of associated peritonitis were considered. Laparoscopic surgery was performed, which showed a prominent diverticulum dependent on the small intestine, located 25 cm from the ileocecal valve, which was perforated, for which an enterotomy of approximately 5 cm of the small intestine and a lateral-lateral anastomosis with mechanical suture were performed, after washing the abdominal cavity and finally closing the abdominal wall. The pathological anatomy described a segment of the small intestine with a lesion of saccular appearance, measuring 35 x 25 mm, which after the histological cuts of its wall showed ulceration of the mucosa and submucosa and acute inflammation in the serosa, without significant alteration of the enteric wall away from the lesion. This description confirmed the diagnosis of perforated Meckel's diverticulitis, proposed by previously described images.\n", + "fulltext_subclaims": [ + "The patient is a 65-year-old man.", + "The patient has a history of hypertension.", + "The patient has a history of smoking.", + "The patient was admitted from another institution.", + "The patient was diagnosed with acute abdomen.", + "The patient reported approximately 48 hours of pain in the lower abdominal area.", + "The pain did not subside with common analgesics.", + "The patient had associated nausea.", + "On admission, the patient had a positive Blumberg sign.", + "A blood count showed a leukocytosis of 18,320 mm³.", + "A blood count showed a neutrophilia of 85%.", + "A computed tomography (CT) of the abdomen with intravenous contrast was performed.", + "The CT showed a saccular image of 52 x 41 mm dependent on the loop of the terminal ileum.", + "The CT showed a pattern of bread crumbs.", + "The CT showed peripheral enhancement.", + "The CT showed rarefaction of adjacent fat.", + "The CT showed findings related to Meckel's diverticulitis.", + "The CT showed pneumoperitoneum.", + "The CT showed free liquid in the abdominal cavity.", + "Signs of associated peritonitis were considered.", + "Laparoscopic surgery was performed.", + "The surgery showed a prominent diverticulum dependent on the small intestine.", + "The diverticulum was located 25 cm from the ileocecal valve.", + "The diverticulum was perforated.", + "An enterotomy of approximately 5 cm of the small intestine was performed.", + "A lateral-lateral anastomosis with mechanical suture was performed.", + "The abdominal cavity was washed.", + "The abdominal wall was closed.", + "The pathological anatomy described a segment of the small intestine with a lesion of saccular appearance.", + "The lesion measured 35 x 25 mm.", + "Histological cuts showed ulceration of the mucosa and submucosa.", + "Histological cuts showed acute inflammation in the serosa.", + "There was no significant alteration of the enteric wall away from the lesion.", + "The description confirmed the diagnosis of perforated Meckel's diverticulitis." + ], + "summary": "We describe the case of a 65-year-old man, who was referred from another institution with a diagnosis of acute abdomen. On physical examination, he presented signs of peritoneal irritation with evidence of leukocytosis and neutrophilia in the admission blood count. Computed tomography of the abdomen with intravenous contrast was performed, which was interpreted as Meckel's diverticulitis complicated, being corroborated during the surgical act and confirmed by pathological anatomy.\n", + "summary_subclaims": [ + "The patient is a 65-year-old man.", + "The patient was referred from another institution.", + "The patient was diagnosed with acute abdomen.", + "On physical examination, the patient presented signs of peritoneal irritation.", + "The admission blood count showed leukocytosis.", + "The admission blood count showed neutrophilia.", + "Computed tomography of the abdomen with intravenous contrast was performed.", + "The computed tomography was interpreted as Meckel's diverticulitis complicated.", + "The diagnosis was corroborated during the surgical act.", + "The diagnosis was confirmed by pathological anatomy." + ] + }, + { + "id": "multiclinsum_test_2110_en.txt", + "fulltext": "A 78-year-old male patient presented with 5 months of intermittent cervicalgia and several weeks of a progressive right hemiparesis, up to hemiplegia (0/5), brisk upper and lower extremity reflexes, bilateral Hoffmann’s and Babinski signs, left hemisensory dysesthesias, and urinary incontinence.\nThe cervical spinal MRI revealed an intramedullary expansive lesion (10 mm×15 mm) at C1–C2 that markedly enhanced with gadolinium . As the differential diagnosis included potential metastatic disease, a total body computed tomography (CT) scan was performed that revealed a large mass (about 85 mm in size) involving the upper polar region and the middle third of the right kidney, extending to the adrenal gland, and ipsilateral psoas muscle . A CT- guided fine-needle ago-biopsy of established the diagnosis of an RCC, also making it most likely that the C1–C2 lesion was an RCC metastasis (Stage IV).\nUtilizing intraoperative neurophysiological monitoring, a C1–C2 laminectomy was performed. Through a posterior C2, myelotomy, and the lesion were macroscopically fully resected . Postoperatively, the patient presented a slight motor improvement, with the right hemiparesis (2/5) and left-sided hemisensory deficit.\nThe histological examination revealed large cells with marked anaplasia. Immunostaining was negative for cytokeratin, GFAP, S-100, and HMB-45 but positive for intermediate vimentin filaments. Together, these studies confirmed the diagnosis of an RCC.\nThe 1-week postoperative cervical spine MRI showed postoperative changes, but full lesion excision . The patient was discharged to a neuromotor rehabilitation center and underwent chemotherapy and radiotherapy for RCC. Fourteen months later, the patient died due to metastatic RCC.", + "fulltext_subclaims": [ + "The patient was a 78-year-old male.", + "The patient had 5 months of intermittent cervicalgia.", + "The patient had several weeks of a progressive right hemiparesis, up to hemiplegia (0/5).", + "The patient had brisk upper and lower extremity reflexes.", + "The patient had bilateral Hoffmann’s and Babinski signs.", + "The patient had left hemisensory dysesthesias.", + "The patient had urinary incontinence.", + "The cervical spinal MRI revealed an intramedullary expansive lesion (10 mm×15 mm) at C1–C2.", + "The lesion at C1–C2 markedly enhanced with gadolinium.", + "A total body CT scan was performed.", + "The CT scan revealed a large mass (about 85 mm in size) involving the upper polar region and the middle third of the right kidney.", + "The mass extended to the adrenal gland.", + "The mass extended to the ipsilateral psoas muscle.", + "A CT-guided fine-needle ago-biopsy established the diagnosis of an RCC.", + "The C1–C2 lesion was most likely an RCC metastasis.", + "A C1–C2 laminectomy was performed.", + "Intraoperative neurophysiological monitoring was used.", + "The lesion was macroscopically fully resected.", + "Postoperatively, the patient had a slight motor improvement.", + "The right hemiparesis improved to 2/5.", + "The histological examination revealed large cells with marked anaplasia.", + "Immunostaining was negative for cytokeratin.", + "Immunostaining was negative for GFAP.", + "Immunostaining was negative for S-100.", + "Immunostaining was negative for HMB-45.", + "Immunostaining was positive for intermediate vimentin filaments.", + "The histological and immunostaining studies confirmed the diagnosis of an RCC.", + "The 1-week postoperative cervical spine MRI showed postoperative changes.", + "The 1-week postoperative MRI showed full lesion excision.", + "The patient was discharged to a neuromotor rehabilitation center.", + "The patient underwent chemotherapy and radiotherapy for RCC.", + "Fourteen months later, the patient died due to metastatic RCC." + ], + "summary": "A 78-year-old male patient presented with intermittent cervicalgia of 5 months duration accompanied by few weeks of a progressive severe right hemiparesis, up to hemiplegia. The magnetic resonance imaging (MRI) examination revealed an intramedullary expansive lesion measuring 10 mm×15 mm at the C1-C2 level; it readily enhanced with contrast. A total body computed tomography (CT) scan documented an 85 mm mass involving the right kidney, extending to the ipsilateral adrenal gland, and posteriorly infiltrating the ipsilateral psoas muscle. The subsequent CT-guided fine-needle biopsy confirmed the diagnosis of an RCC (Stage IV). The patient next underwent total surgical total removal of the C1-C2 intramedullary mass, following which he exhibited a slight motor improvement, with the right hemiparesis (2/5). He died after 14 months due to global RCC tumor progression.", + "summary_subclaims": [ + "The patient is a 78-year-old male.", + "The patient had intermittent cervicalgia of 5 months duration.", + "The patient had progressive severe right hemiparesis for a few weeks.", + "The MRI revealed an intramedullary expansive lesion at the C1-C2 level.", + "The lesion measured 10 mm×15 mm.", + "The lesion readily enhanced with contrast.", + "The CT scan documented an 85 mm mass involving the right kidney.", + "The mass extended to the ipsilateral adrenal gland.", + "The mass posteriorly infiltrated the ipsilateral psoas muscle.", + "The CT-guided fine-needle biopsy confirmed the diagnosis of an RCC.", + "The RCC was Stage IV.", + "The patient underwent total surgical removal of the C1-C2 intramedullary mass.", + "After surgery, the patient exhibited a slight motor improvement.", + "The right hemiparesis was 2/5 after surgery.", + "The patient died after 14 months.", + "The cause of death was global RCC tumor progression." + ] + }, + { + "id": "multiclinsum_test_2350_en.txt", + "fulltext": "First case is a 62-year-old female patient hospitalized in our clinic due to chest pain with a history of arterial hypertension and diabetes mellitus. Cardiac biomarkers showed: serum creatinine kinase level of 82 IU/L, creatinine kinase-myocardial band level of 33.6U/L and troponin-T level of 684ug/L. Electrocardiography characterized with ST segment depression in V1-V3. Transthoracic echocardiography (TTE) presented regional wall motion abnormality in the entire severely hypokinetic inferior wall.\nThe invasive coronary angiography revealed the left coronary artery arising from the right coronary sinus sharing a same ostium with right coronary artery . The proximally and distally stenosed left anterior descending artery (LAD) associates with calcified atherosclerotic medial and distal right coronary artery (RCA) stenosis. The second case is a 47-year-old male who presented to emergency department with chest pain. He also had arterial hypertension and positive familial history for ischemic heart disease. Cardiac biomarkers: serum creatinine kinase, creatine kinase-myocardial band and troponin-T presented with normal values. Electrocardiography showed atypical ST segment changes in leads V4-V6. Transthoracic echocardiography (TTE) did not present regional wall motion abnormalities.\nA coronary angiogram showed an anomalous right coronary artery arising from the left Valsalva sinus from a separate ostia with the left coronary artery . Medial and distal segments of LAD were tortuous.", + "fulltext_subclaims": [ + "The first case is a 62-year-old female patient hospitalized in our clinic due to chest pain.", + "The patient has a history of arterial hypertension.", + "The patient has a history of diabetes mellitus.", + "Cardiac biomarkers showed a serum creatinine kinase level of 82 IU/L.", + "Cardiac biomarkers showed a creatinine kinase-myocardial band level of 33.6 U/L.", + "Cardiac biomarkers showed a troponin-T level of 684 ug/L.", + "Electrocardiography showed ST segment depression in V1-V3.", + "Transthoracic echocardiography presented regional wall motion abnormality in the entire severely hypokinetic inferior wall.", + "Invasive coronary angiography revealed the left coronary artery arising from the right coronary sinus sharing a same ostium with the right coronary artery.", + "The proximally and distally stenosed left anterior descending artery associates with calcified atherosclerotic medial and distal right coronary artery stenosis.", + "The second case is a 47-year-old male who presented to the emergency department with chest pain.", + "The patient had arterial hypertension.", + "The patient had a positive familial history for ischemic heart disease.", + "Cardiac biomarkers showed normal values for serum creatinine kinase.", + "Cardiac biomarkers showed normal values for creatine kinase-myocardial band.", + "Cardiac biomarkers showed normal values for troponin-T.", + "Electrocardiography showed atypical ST segment changes in leads V4-V6.", + "Transthoracic echocardiography did not present regional wall motion abnormalities.", + "A coronary angiogram showed an anomalous right coronary artery arising from the left Valsalva sinus from a separate ostia with the left coronary artery.", + "The medial and distal segments of the left anterior descending artery were tortuous." + ], + "summary": "We report two cases, the first case the coronary angiography showed the left coronary artery arising from the right coronary sinus, presenting with proximally and distally stenosed left anterior descending artery (LAD), associated with medial and distal stenosed right coronary artery (RCA). The second case the coronary angiography revealed the right coronary artery arising from the left coronary sinus, associated with tortuous medial and distal segments of left anterior descending artery (LAD), without atherosclerotic changes. The first case successfully underwent treatment procedures based on guidelines for revascularization.", + "summary_subclaims": [ + "The first case the coronary angiography showed the left coronary artery arising from the right coronary sinus.", + "The first case presented with proximally and distally stenosed left anterior descending artery.", + "The first case had associated medial and distal stenosed right coronary artery.", + "The second case the coronary angiography revealed the right coronary artery arising from the left coronary sinus.", + "The second case had associated tortuous medial and distal segments of left anterior descending artery.", + "The second case had no atherosclerotic changes.", + "The first case successfully underwent treatment procedures based on guidelines for revascularization." + ] + }, + { + "id": "multiclinsum_test_619_en.txt", + "fulltext": "A 27-year-old, Caucasian female with a past medical history of tachycardia and ethanol dependence presented to the emergency department (ED) for possible psychosis in the setting of ethanol withdrawal. Two days previously, the patient was admitted to an outside hospital for management of ethanol withdrawal and was treated with intravenous fluids but not BNZs. She removed her IV and left the hospital before being formally discharged, but the family brought her to our hospital with a report of paranoia and believing people outside her home were trying to kill her. Her last known ethanol consumption was 4 days prior, and alcohol, BNZs, and barbiturates were not detected in her serum or urine. She reported at least five “heavy pours” of vodka every day, and had consumed this amount for a few years. Examination was significant for tachycardia (127–132 beats per minute), high blood pressure (ranging from 143 to 149/102 to 103 mmHg), and mild tenderness to palpation to bilateral upper abdominal quadrants. She was calm, fully oriented, and with organized thought process, but endorsed paranoia regarding family members being out to get her and hearing voices outside her head talking about her. A medical workup for delirium revealed normal complete blood count, a comprehensive metabolic panel with mildly elevated transaminases [aspartate aminotransferase (AST) 94 U/L; alanine transaminase (ALT) 72 U/L], and a noncontrast computed tomogram of the brain with mild diffuse volume loss greater than expected for her age. These abnormalities were consistent with her drinking history and not indicative of a separate process. No substances were present in urine or serum toxicology. She was negative for coronavirus (COVID), human immunodeficiency virus (HIV), and hepatitis panel. She expressed interest in achieving sobriety from ethanol. She was first given lorazepam 2 mg orally and started on chlordiazepoxide 25 mg twice daily because her pulse and blood pressure remained elevated. Within 2 hours of every chlordiazepoxide dose, she became acutely confused and agitated, reporting visual and auditory hallucinations and stating that there were people on the other side of the door who were coming after her. After two doses of chlordiazepoxide (total of 50 mg, which is equivalent to 2 mg lorazepam), it was discontinued and she was treated with 2 mg of intramuscular lorazepam and a subsequent dose of oral lorazepam 2 mg, which were associated with improvement of her agitation. All BNZs were subsequently held. The next day, the patient was calm, coherent, with organized thought, and no hallucinations or paranoia. She remained that way over an extended observation period of over 10 hours. She was then referred to a substance treatment program where she did not exhibit any psychosis, and did not require additional BNZ medication.\nOur institutional human subjects protection program allowed submission of this case presentation (IRB number 22.1081). Additionally, written informed consent was obtained from the patient for publication of this case report.", + "fulltext_subclaims": [ + "The patient is a 27-year-old, Caucasian female.", + "She has a past medical history of tachycardia.", + "She has a past medical history of ethanol dependence.", + "She presented to the emergency department for possible psychosis in the setting of ethanol withdrawal.", + "Two days previously, the patient was admitted to an outside hospital for management of ethanol withdrawal.", + "She was treated with intravenous fluids but not BNZs at the outside hospital.", + "She removed her IV and left the hospital before being formally discharged.", + "The family brought her to our hospital with a report of paranoia.", + "Her last known ethanol consumption was 4 days prior.", + "Alcohol, BNZs, and barbiturates were not detected in her serum or urine.", + "She reported at least five 'heavy pours' of vodka every day.", + "She had consumed this amount for a few years.", + "Examination was significant for tachycardia (127–132 beats per minute).", + "Examination was significant for high blood pressure (ranging from 143 to 149/102 to 103 mmHg).", + "Examination showed mild tenderness to palpation to bilateral upper abdominal quadrants.", + "She was calm, fully oriented, and with organized thought process.", + "A medical workup for delirium revealed normal complete blood count.", + "A comprehensive metabolic panel showed mildly elevated transaminases.", + "A noncontrast computed tomogram of the brain showed mild diffuse volume loss greater than expected for her age.", + "These abnormalities were consistent with her drinking history.", + "These abnormalities were not indicative of a separate process.", + "No substances were present in urine or serum toxicology.", + "She was negative for coronavirus (COVID).", + "She was negative for human immunodeficiency virus (HIV).", + "She was negative for hepatitis panel.", + "She expressed interest in achieving sobriety from ethanol.", + "She was first given lorazepam 2 mg orally.", + "She was started on chlordiazepoxide 25 mg twice daily.", + "Within 2 hours of every chlordiazepoxide dose, she became acutely confused and agitated.", + "After two doses of chlordiazepoxide (total of 50 mg, which is equivalent to 2 mg lorazepam), it was discontinued.", + "She was treated with 2 mg of intramuscular lorazepam.", + "A subsequent dose of oral lorazepam 2 mg was given.", + "All BNZs were subsequently held.", + "The next day, the patient was calm, coherent, with organized thought.", + "She remained that way over an extended observation period of over 10 hours.", + "She was then referred to a substance treatment program.", + "In the substance treatment program, she did not exhibit any psychosis.", + "She did not require additional BNZ medication.", + "Our institutional human subjects protection program allowed submission of this case presentation.", + "Written informed consent was obtained from the patient for publication of this case report." + ], + "summary": "A 27-year-old, Caucasian female with ethanol dependence who had objective symptoms of withdrawal experienced worsening of her delirium after administration of chlordiazepoxide, but improved with lorazepam and cleared with discontinuation of benzodiazepine administration.", + "summary_subclaims": [ + "The patient is a 27-year-old, Caucasian female.", + "The patient has ethanol dependence.", + "The patient had objective symptoms of withdrawal.", + "The patient experienced worsening of her delirium after administration of chlordiazepoxide.", + "The patient improved with lorazepam.", + "The patient's delirium cleared with discontinuation of benzodiazepine administration." + ] + }, + { + "id": "multiclinsum_test_2025_en.txt", + "fulltext": "An 83-year-old man noticed a left submandibular mass and visited our Department of Oral Surgery. He had no B symptoms. His family history was unremarkable, although he had a history of renal insufficiency. A physical examination revealed an elastic hard tumor (diameter: 4 cm) that was well-demarcated and had not adhered to the surrounding tissue. The covering skin was normal, and the patient reported not experiencing spontaneous pain or tenderness. Laboratory testing revealed slight anemia (red blood cell count: 385 × 104/μL, hemoglobin levels: 11.7 g/dL) and leukopenia (white blood cell count: 3,900/μL), although his serum lactate dehydrogenase levels were not elevated (207 IU/L). Levels of soluble interleukin-2 receptor were markedly elevated (2,730 IU/mL), although we did not detect elevated titers of antibodies to human T-cell leukemia virus-1 or human immunodeficiency virus (HIV). Computed tomography and diffusion-weighted magnetic resonance imaging revealed a left submandibular tumorous lesion and multiple swollen lymph nodes (the left cervical and inguinal nodes) . Magnetic resonance imaging also revealed multiple high-intensity areas in the vertebrae, bilateral ribs, and ilia, although there were no abnormalities in the mediastinum or abdomen. We obtained a biopsy specimen from the submandibular lesion, which supported our initial pathological diagnosis of anaplastic large cell lymphoma (ALCL), although a hematopathological consultant helped us make a final diagnosis of EBV-positive DLBCL. The patient underwent 2 courses of chemotherapy using the THP-COP regimen and achieved partial remission, although the tumor was ultimately resistant to the following therapies: molecular-targeted therapy using brentuximab vedotin, THP-COP (4’-O-tetrahydropyranyl adriamycin, cyclophosphamide, Oncovin®, prednisolone), and EPOCH (etoposide, prednisolone, Oncovin®, cyclophosphamide, hydroxydaunorubicin). The patient was alive with progressive disease at the 9-month follow-up.\nHematoxylin-eosin (HE) staining revealed that the lymph node architecture was effaced and diffusely occupied by infiltrative large lymphoid cells. Many foci of necrosis were visible, and the lesion was comprised of centroblast-like cells (a large vesicular nucleus and several conspicuous nucleoli), immunoblast-like cells (prominent central nucleoli), and plasmacytic cells . There were scattered large multinuclear cells with prominent nucleoli, including large cells that were similar to Hodgkin/Reed-Sternberg cells (HRS-like cells) .\nThe initial IHC revealed that the tumor cells were positive for CD30 and MUM-1, but negative for CD3, CD4, CD5, CD8, CD10, CD19, CD20, CD23, CD38, CD45, CD45RO, CD56, CD79a, CD138, Pax-5, immunoglobulin light chains (κ and λ), epithelial membrane antigen (EMA), anaplastic lymphoma kinase (ALK), Bcl-2, and Bcl-6 . These results could not define cell lineage and histological type of the tumor. Additional IHC revealed that the tumor cells were positive for B-cell-specific transcription factors (Oct-2 and BOB.1), which confirmed B-cell derivation of the tumor cells . In situ hybridization revealed clear positive signals for EBV-encoded small RNAs in the nuclei of the tumor cells . The tumor cells were negative for LANA-1 (a product of human herpesvirus-8), and the Ki-67 labeling index was very high (approximately 80%).\nWe performed gene rearrangement testing using the BIOMED-2 multiplex polymerase chain reaction-based method, which revealed clonal rearrangement of the immunoglobulin heavy chain and light chain genes. No clonal rearrangement was detected in the T-cell receptor genes.", + "fulltext_subclaims": [ + "The patient was an 83-year-old man.", + "He noticed a left submandibular mass.", + "He had no B symptoms.", + "His family history was unremarkable.", + "He had a history of renal insufficiency.", + "A physical examination revealed an elastic hard tumor.", + "The tumor had a diameter of 4 cm.", + "The tumor was well-demarcated.", + "The tumor had not adhered to the surrounding tissue.", + "The covering skin was normal.", + "The patient reported not experiencing spontaneous pain.", + "The patient reported not experiencing tenderness.", + "Laboratory testing revealed slight anemia.", + "The red blood cell count was 385 × 104/μL.", + "Hemoglobin levels were 11.7 g/dL.", + "White blood cell count was 3,900/μL.", + "Serum lactate dehydrogenase levels were 207 IU/L.", + "Serum lactate dehydrogenase levels were not elevated.", + "Soluble interleukin-2 receptor levels were markedly elevated.", + "Antibodies to human T-cell leukemia virus-1 were not detected.", + "Antibodies to human immunodeficiency virus (HIV) were not detected.", + "Computed tomography revealed a left submandibular tumorous lesion.", + "Diffusion-weighted magnetic resonance imaging revealed multiple swollen lymph nodes.", + "Multiple high-intensity areas were visible in the vertebrae.", + "Multiple high-intensity areas were visible in the bilateral ribs.", + "Multiple high-intensity areas were visible in the ilia.", + "A biopsy specimen was obtained from the submandibular lesion.", + "The initial pathological diagnosis was anaplastic large cell lymphoma (ALCL).", + "The final diagnosis was EBV-positive DLBCL.", + "The patient underwent 2 courses of chemotherapy using the THP-COP regimen.", + "The patient achieved partial remission.", + "The tumor was ultimately resistant to molecular-targeted therapy using brentuximab vedotin.", + "The tumor was ultimately resistant to THP-COP.", + "The tumor was ultimately resistant to EPOCH.", + "The patient was alive with progressive disease at the 9-month follow-up.", + "Hematoxylin-eosin (HE) staining revealed that the lymph node architecture was effaced.", + "The lesion was comprised of centroblast-like cells.", + "The lesion was comprised of immunoblast-like cells.", + "The lesion was comprised of plasmacytic cells.", + "There were scattered large multinuclear cells with prominent nucleoli.", + "The initial IHC revealed that the tumor cells were positive for CD30.", + "The initial IHC revealed that the tumor cells were positive for MUM-1.", + "The initial IHC revealed that the tumor cells were negative for CD3.", + "The initial IHC revealed that the tumor cells were negative for CD4.", + "The initial IHC revealed that the tumor cells were negative for CD5.", + "The initial IHC revealed that the tumor cells were negative for CD8.", + "The initial IHC revealed that the tumor cells were negative for CD10.", + "The initial IHC revealed that the tumor cells were negative for CD19.", + "The initial IHC revealed that the tumor cells were negative for CD20.", + "The initial IHC revealed that the tumor cells were negative for CD23.", + "The initial IHC revealed that the tumor cells were negative for CD38.", + "The initial IHC revealed that the tumor cells were negative for CD45.", + "The initial IHC revealed that the tumor cells were negative for CD45RO.", + "The initial IHC revealed that the tumor cells were negative for CD56.", + "The initial IHC revealed that the tumor cells were negative for CD79a.", + "The initial IHC revealed that the tumor cells were negative for CD138.", + "The initial IHC revealed that the tumor cells were negative for Pax-5.", + "The initial IHC revealed that the tumor cells were negative for immunoglobulin light chains.", + "The initial IHC revealed that the tumor cells were negative for epithelial membrane antigen (EMA).", + "The initial IHC revealed that the tumor cells were negative for anaplastic lymphoma kinase (ALK).", + "The initial IHC revealed that the tumor cells were negative for Bcl-2.", + "The initial IHC revealed that the tumor cells were negative for Bcl-6.", + "Additional IHC revealed that the tumor cells were positive for B-cell-specific transcription factors.", + "In situ hybridization revealed clear positive signals for EBV-encoded small RNAs.", + "The tumor cells were negative for LANA-1.", + "The Ki-67 labeling index was approximately 80%.", + "Gene rearrangement testing revealed clonal rearrangement of the immunoglobulin heavy chain.", + "Gene rearrangement testing revealed clonal rearrangement of the immunoglobulin light chain.", + "No clonal rearrangement was detected in the T-cell receptor genes." + ], + "summary": "An 83-year-old man presented with a submandibular tumor. Histology of a lymph node biopsy specimen revealed diffuse proliferation of centroblast- or immunoblast-like lymphoid cells with plasmacytic differentiation. Scattered Hodgkin/Reed-Sternberg-like cells were also visible. A routine immunohistochemistry antibody panel revealed that the tumor cells were negative for B-cell and T-cell markers (i.e., CD3, CD19, CD20, CD38, CD45RO, CD79a, CD138, and Pax-5), but were positive for CD30 and MUM-1, not defining the lineage of tumor cells. The final diagnosis of EBV-positive DLBCL was confirmed based on the expression of B-cell-specific transcription factors (Oct-2 and BOB.1), PCR-based identification of monoclonal rearrangement of the immunoglobulin genes, and the presence of EBV-encoded small RNAs in the tumor cells (identified using in situ hybridization).", + "summary_subclaims": [ + "An 83-year-old man presented with a submandibular tumor.", + "Histology of a lymph node biopsy specimen revealed diffuse proliferation of centroblast- or immunoblast-like lymphoid cells with plasmacytic differentiation.", + "Scattered Hodgkin/Reed-Sternberg-like cells were also visible.", + "A routine immunohistochemistry antibody panel revealed that the tumor cells were negative for B-cell and T-cell markers (i.e., CD3, CD19, CD20, CD38, CD45RO, CD79a, CD138, and Pax-5).", + "The tumor cells were positive for CD30 and MUM-1.", + "The final diagnosis of EBV-positive DLBCL was confirmed.", + "The diagnosis was confirmed based on the expression of B-cell-specific transcription factors (Oct-2 and BOB.1).", + "The diagnosis was confirmed based on PCR-based identification of monoclonal rearrangement of the immunoglobulin genes.", + "The diagnosis was confirmed based on the presence of EBV-encoded small RNAs in the tumor cells.", + "The presence of EBV-encoded small RNAs was identified using in situ hybridization." + ] + }, + { + "id": "multiclinsum_test_701_en.txt", + "fulltext": "The patient was a previously healthy 73-year-old female who underwent curative resection for GBC (pT2N0M0 according to the eighth International union against cancer TNM classification). We performed next-generation sequencing (NGS)-based genomic profiling of the resected specimen using the NGS gene panel, Oncomine® Comprehensive Assay version 3 (OCA v.3, Thermo Fisher Scientific), which revealed ERBB2 Ser310Phe (c.929C>T; VAF, 18%) and TP53 Ser241Tyr (c.722C>A; VAF, 19%) mutations. One year later, a hepatic lesion was observed on follow-up imaging and she underwent surgical total biopsy for a pathological diagnosis.\nA patient had no symptoms and was in good health at the time of total biopsy.\nThe patient had no previous medical history.\nThe patient’s physical examination was not remarkable and laboratory testing was within normal limits, including tumor markers, such as CA19-9 and CEA.\nContrasted computed tomography (CT) showed an ill-defined low attenuation lesion in the posterior lobe of the liver .\nThe hepatic lesion was histologically diagnosed as well-differentiated adenocarcinoma and the histological findings of the hepatic lesion were similar to those of GBC . Therefore, the lesion was considered a metastasis. Moreover, we performed genomic profiling from the liver tumor using the NGS panel, Oncomine® Target Test system (OTT, Thermo Fisher Scientific). This revealed ERBB2 Ser310Phe (c.929C>T; VAF, 26%), which was identical to the mutation detected in the sequencing result of the primary site; thus, the liver tumor was the most consistent with a metastasis of GBC rather than localized ICC. To evaluate HER2 overexpression in tumor cells, we performed immunohistochemistry of HER2, which was negative (HER2 score 0). Since TP53 was not included in the gene list of OTTs, TP53 mutation status at the metastatic site was not assessed.", + "fulltext_subclaims": [ + "The patient was a previously healthy 73-year-old female.", + "The patient underwent curative resection for GBC.", + "The tumor was classified as pT2N0M0 according to the eighth International Union against Cancer TNM classification.", + "Next-generation sequencing-based genomic profiling of the resected specimen was performed using the Oncomine® Comprehensive Assay version 3.", + "The genomic profiling revealed ERBB2 Ser310Phe (c.929C>T; VAF, 18%) mutation.", + "The genomic profiling revealed TP53 Ser241Tyr (c.722C>A; VAF, 19%) mutation.", + "One year later, a hepatic lesion was observed on follow-up imaging.", + "The patient underwent surgical total biopsy for a pathological diagnosis.", + "The patient had no symptoms and was in good health at the time of total biopsy.", + "The patient had no previous medical history.", + "The patient’s physical examination was not remarkable.", + "Laboratory testing was within normal limits, including tumor markers such as CA19-9 and CEA.", + "Contrasted computed tomography showed an ill-defined low attenuation lesion in the posterior lobe of the liver.", + "The hepatic lesion was histologically diagnosed as well-differentiated adenocarcinoma.", + "The histological findings of the hepatic lesion were similar to those of GBC.", + "The lesion was considered a metastasis.", + "Genomic profiling from the liver tumor was performed using the Oncomine® Target Test system.", + "This revealed ERBB2 Ser310Phe (c.929C>T; VAF, 26%).", + "The ERBB2 mutation detected in the liver tumor was identical to the mutation detected in the primary site.", + "The liver tumor was the most consistent with a metastasis of GBC rather than localized ICC.", + "Immunohistochemistry of HER2 was performed.", + "HER2 immunohistochemistry was negative (HER2 score 0).", + "TP53 was not included in the gene list of the Oncomine® Target Test system.", + "TP53 mutation status at the metastatic site was not assessed." + ], + "summary": "We present a 73-year-old female patient who underwent curative resection for GBC harboring epidermal growth factor receptor 2 (ERBB2) activating mutation on next-generation sequencing (NGS)-based genomic testing. One year later, a hepatic lesion was observed on follow-up imaging and she underwent surgical resection for a pathological diagnosis. The histological findings of the hepatic lesion were similar to those of the primary lesion. Additionally, using NGS panel testing, the hepatic lesion was found to have ERBB2 activating mutation, which is the identical mutation detected in the sequencing result of the primary site. ERBB2 activating mutation occurs more frequently in GBC than ICA and ECA. Therefore, in the present case, we think this molecular finding potentiated the diagnosis of the liver mass toward a metastatic recurrence. Additionally, this patient underwent HER2-targeted treatment with lapatinib in combination with capecitabin and obtained clinical benefit.", + "summary_subclaims": [ + "The patient is a 73-year-old female.", + "The patient underwent curative resection for GBC.", + "The GBC harbored an epidermal growth factor receptor 2 (ERBB2) activating mutation.", + "The ERBB2 activating mutation was detected on next-generation sequencing (NGS)-based genomic testing.", + "One year later, a hepatic lesion was observed on follow-up imaging.", + "The patient underwent surgical resection for a pathological diagnosis.", + "The histological findings of the hepatic lesion were similar to those of the primary lesion.", + "The hepatic lesion was found to have ERBB2 activating mutation.", + "The ERBB2 activating mutation detected in the hepatic lesion is the identical mutation detected in the sequencing result of the primary site.", + "ERBB2 activating mutation occurs more frequently in GBC than ICA and ECA.", + "The molecular finding potentiated the diagnosis of the liver mass toward a metastatic recurrence.", + "The patient underwent HER2-targeted treatment with lapatinib in combination with capecitabin.", + "The patient obtained clinical benefit." + ] + }, + { + "id": "multiclinsum_test_1048_en.txt", + "fulltext": "The patient is a 54-year-old gentleman, who presented with a few months of mid-epigastric pain, nausea and vomiting with associated weight loss in February 2012. CT and MRI scans revealed a 3.3 × 3.1 cm pancreatic head mass encasing superior mesenteric artery and vein with associated mesenteric periportal lymphadenopathy. He also had sub-centimeter lung nodules presumed to be metastatic deposits. He thus had a clinical stage 4 unresectable pancreatic cancer. Genomic analysis of tumor biopsies revealed the presence of KRAS mutation (G12D) and loss of CDKN2A/B.\nThe patient was placed on a clinical trial with first-line treatment of Reolysin and gemcitabine, receiving cycle one day one on March 2012. Reolysin was administered at a dose of 1 × 1010 TCID50 IV on days 1, 2, 8, and 9 (immediately after gemcitabine on days 1 and 8) in combination with 800 mg/m2 IV gemcitabine on days 1 and 8, with 21-day cycles. The patient displayed a clinical response with improvement in cancer-related pain. The best radiographical response was documented as stable disease by Response Evaluation Criteria in Solid Tumors (RECIST) guidelines .\nWith the patient on treatment, a biopsy of the pancreatic mass was performed after cycle 25 day 8 in February 2014. The biopsy features were consistent with the diagnosis of pancreatic adenocarcinoma, with confirmed KRAS mutation (G12D) and loss of CDKN2A/B. Immunohistochemistry (IHC) was performed on Reolysin-treated or untreated HCT116 colon cancer cells as a positive and negative control for reovirus staining, respectively . Viral replication was detected using antibodies against the reovirus protein, as the presence of viral RNA may not necessarily imply infectious virus particles. A polyclonal antibody, raised in goats, was derived from mature reovirus viral capsid proteins . Importantly, IHC analyses of biopsy specimens from a pancreatic cancer patient revealed strong positivity for reoviral protein and activated caspase 3 within the tumor . Biopsies from pancreatic cancer patients frequently contain benign fat, which may serve as an excellent internal negative control. Images of the stained fat cells were negative for reovirus and active caspase-3 and were from the same tissues that displayed positive staining for reovirus and active caspase-3 . Serial section analysis showed a very high concordance of reoviral protein and activated caspase-3, which is characteristic of a productive reovirus infection. In addition, co-expression analysis demonstrated that the reoviral protein and active caspase-3 were being expressed in many of the same cancer cells . Our preclinical studies with Reolysin identified induction of ER stress and NOXA to be key determinants for Reolysin-mediated apoptosis [, ]. In agreement with the induction of active caspase-3, we also noted a significant increase in the expression of GRP78/BIP, which is commonly induced following ER stress and NOXA in the biopsy sample following Reolysin and gemcitabine treatment .\nToxicities were manageable and included grade 1 fever likely due to Reolysin and grade 3 thrombocytopenia and neutropenia due to gemcitabine. The patient also had a biliary obstruction, which required stenting in November 2013. He completed 27 cycles of treatment with the last one in April 2014. At this time, he presented with disease progression with ascites and jaundice.", + "fulltext_subclaims": [ + "The patient is a 54-year-old gentleman.", + "He presented with a few months of mid-epigastric pain, nausea and vomiting with associated weight loss in February 2012.", + "CT and MRI scans revealed a 3.3 × 3.1 cm pancreatic head mass encasing superior mesenteric artery and vein.", + "There was associated mesenteric periportal lymphadenopathy.", + "He had sub-centimeter lung nodules presumed to be metastatic deposits.", + "He had a clinical stage 4 unresectable pancreatic cancer.", + "Genomic analysis of tumor biopsies revealed the presence of KRAS mutation (G12D).", + "Genomic analysis of tumor biopsies revealed loss of CDKN2A/B.", + "The patient was placed on a clinical trial with first-line treatment of Reolysin and gemcitabine.", + "He received cycle one day one on March 2012.", + "Reolysin was administered at a dose of 1 × 1010 TCID50 IV on days 1, 2, 8, and 9.", + "Reolysin was administered immediately after gemcitabine on days 1 and 8.", + "Gemcitabine was administered at 800 mg/m2 IV on days 1 and 8.", + "The treatment cycles were 21 days.", + "The patient displayed a clinical response with improvement in cancer-related pain.", + "The best radiographical response was documented as stable disease by Response Evaluation Criteria in Solid Tumors (RECIST) guidelines.", + "A biopsy of the pancreatic mass was performed after cycle 25 day 8 in February 2014.", + "The biopsy features were consistent with the diagnosis of pancreatic adenocarcinoma.", + "KRAS mutation (G12D) was confirmed in the biopsy.", + "Loss of CDKN2A/B was confirmed in the biopsy.", + "Immunohistochemistry (IHC) was performed on Reolysin-treated HCT116 colon cancer cells as a positive control for reovirus staining.", + "IHC was performed on untreated HCT116 colon cancer cells as a negative control for reovirus staining.", + "Viral replication was detected using antibodies against the reovirus protein.", + "The presence of viral RNA may not necessarily imply infectious virus particles.", + "A polyclonal antibody, raised in goats, was derived from mature reovirus viral capsid proteins.", + "IHC analyses of biopsy specimens from a pancreatic cancer patient revealed strong positivity for reoviral protein.", + "IHC analyses of biopsy specimens from a pancreatic cancer patient revealed strong positivity for activated caspase 3 within the tumor.", + "Biopsies from pancreatic cancer patients frequently contain benign fat.", + "Benign fat may serve as an excellent internal negative control.", + "Images of the stained fat cells were negative for reovirus.", + "Images of the stained fat cells were negative for active caspase-3.", + "The fat cells were from the same tissues that displayed positive staining for reovirus and active caspase-3.", + "Serial section analysis showed a very high concordance of reoviral protein and activated caspase-3.", + "The high concordance is characteristic of a productive reovirus infection.", + "Co-expression analysis demonstrated that the reoviral protein and active caspase-3 were being expressed in many of the same cancer cells.", + "Preclinical studies with Reolysin identified induction of ER stress and NOXA to be key determinants for Reolysin-mediated apoptosis.", + "A significant increase in the expression of GRP78/BIP was noted in the biopsy sample following Reolysin and gemcitabine treatment.", + "Toxicities included grade 1 fever likely due to Reolysin.", + "Toxicities included grade 3 thrombocytopenia due to gemcitabine.", + "Toxicities included grade 3 neutropenia due to gemcitabine.", + "The patient had a biliary obstruction requiring stenting in November 2013.", + "He completed 27 cycles of treatment.", + "The last treatment cycle was in April 2014.", + "At this time, he presented with disease progression.", + "He presented with ascites.", + "He presented with jaundice." + ], + "summary": "We describe the case of a 54-year old patient diagnosed with pancreatic adenocarcinoma in February 2012. Analysis of a tumor biopsy revealed an activating KRAS mutation (G12D) and the patient was started on first-line treatment with Reolysin in combination with gemcitabine in March 2012. Stable disease was achieved with significant improvement in cancer-related pain. Following 25 cycles of treatment over 23 months, a second biopsy was collected and immunohistochemical analyses revealed the presence of reovirus replication and induction of the ER stress-related gene GRP78/BIP and the pro-apoptotic protein NOXA. Importantly, co-localization of reoviral protein and active caspase-3 was also observed in the biopsy specimen.", + "summary_subclaims": [ + "The patient was a 54-year old.", + "The patient was diagnosed with pancreatic adenocarcinoma in February 2012.", + "Analysis of a tumor biopsy revealed an activating KRAS mutation (G12D).", + "The patient was started on first-line treatment with Reolysin in combination with gemcitabine in March 2012.", + "Stable disease was achieved with significant improvement in cancer-related pain.", + "Following 25 cycles of treatment over 23 months, a second biopsy was collected.", + "Immunohistochemical analyses revealed the presence of reovirus replication.", + "Induction of the ER stress-related gene GRP78/BIP was observed.", + "Induction of the pro-apoptotic protein NOXA was observed.", + "Co-localization of reoviral protein and active caspase-3 was also observed in the biopsy specimen." + ] + }, + { + "id": "multiclinsum_test_2872_en.txt", + "fulltext": "Our patient was a 37-year-old, obese, previously healthy white woman. She was a smoker with no family history of ischemic heart disease. Her recent history involved 3 weeks of respiratory tract infection treated with antibiotics and bronchodilators.\nShe was admitted to our hospital after experiencing a witnessed out-of-hospital cardiac arrest. Bystander CPR was immediately performed for 7 minutes, followed by advanced CPR that included tracheal intubation and mechanical chest compressions provided by the physician-led ambulance team. Her electrocardiogram (ECG) revealed ventricular fibrillation, and she underwent external defibrillation with return of spontaneous circulation. Upon hospital admission, the patient’s blood pressure (BP) was 94/45 mmHg and her heart rate was 110 beats per minute. Her ECG initially showed atrial fibrillation with spontaneous conversion to sinus rhythm and no signs of ST-segment elevations or Q-wave development. Computed tomography (CT) scans of her head and chest were reported normal.\nCoronary angiography revealed a proximal thrombotic occlusion of the left anterior descending (LAD) coronary artery. Successful recanalization of the LAD coronary artery after catheter-based thrombus aspiration, and balloon dilation followed by stent implantation, was verified with normalized anterograde flow (Thrombolysis in Myocardial Infarction grade flow score 3), and an eptifibatide infusion was instituted.\nImmediately after the patient’s arrival in the intensive cardiac care unit (ICCU), a drop in her BP to 60/30 mmHg and a hemoglobin concentration of 4.5 g/dl were noticed. Transfusion was started, the patient’s abdomen was distended, and bedside abdominal ultrasound (US) examination revealed free intraperitoneal fluid. Abdominal CT performed after initial stabilization revealed liver injury with active extravasation from the cranial surface of the right lobe and a massive hemoperitoneum.\nAt that point, the patient was coagulopathic with a body temperature of 33.5 °C. Arterial blood gas analysis revealed a pH of 7.15 and a lactate concentration of 7.4 mmol/L. Angiography and selective transcatheter arterial embolization were successfully performed in combination with evacuation of 4.5 L of intraperitoneal blood through a 16-French pigtail catheter inserted into the right flank under US guidance .\nAfter completion of these procedures, the patient was transfused with a total of 9 U of packed red blood cells, 8 U of plasma, and 2 U of platelets (pooled from five donors each) and was hemodynamically stable. She was weaned off mechanical ventilation 2 days later and thereafter made an uneventful recovery. She was discharged to a local hospital on day 13 without neurological disability.", + "fulltext_subclaims": [ + "The patient was a 37-year-old, obese, previously healthy white woman.", + "She was a smoker.", + "She had no family history of ischemic heart disease.", + "Her recent history involved 3 weeks of respiratory tract infection.", + "She was admitted to the hospital after experiencing a witnessed out-of-hospital cardiac arrest.", + "Bystander CPR was immediately performed for 7 minutes.", + "Advanced CPR included tracheal intubation and mechanical chest compressions.", + "Her ECG revealed ventricular fibrillation.", + "She underwent external defibrillation with return of spontaneous circulation.", + "Upon hospital admission, her blood pressure was 94/45 mmHg.", + "Her ECG initially showed atrial fibrillation with spontaneous conversion to sinus rhythm.", + "Computed tomography scans of her head and chest were reported normal.", + "Coronary angiography revealed a proximal thrombotic occlusion of the left anterior descending coronary artery.", + "Successful recanalization of the LAD coronary artery was verified.", + "A drop in her blood pressure to 60/30 mmHg was noticed.", + "Her hemoglobin concentration was 4.5 g/dl.", + "Bedside abdominal ultrasound examination revealed free intraperitoneal fluid.", + "Abdominal CT revealed liver injury with active extravasation from the cranial surface of the right lobe.", + "The patient was coagulopathic.", + "Arterial blood gas analysis revealed a pH of 7.15.", + "Angiography and selective transcatheter arterial embolization were successfully performed.", + "Evacuation of 4.5 L of intraperitoneal blood was performed.", + "The patient was transfused with a total of 9 U of packed red blood cells.", + "The patient was transfused with 8 U of plasma.", + "The patient was transfused with 2 U of platelets.", + "She was weaned off mechanical ventilation 2 days later.", + "She was discharged to a local hospital on day 13 without neurological disability." + ], + "summary": "A 37-year-old white woman was admitted after out-of-hospital cardiac arrest. Bystander cardiopulmonary resuscitation was immediately performed, followed by advanced cardiopulmonary resuscitation that included tracheal intubation, mechanical chest compressions, and external defibrillation with return of spontaneous circulation. Upon hospital admission, the patient's blood pressure was 94/45 mmHg and her heart rate was 110 beats per minute. Her electrocardiogram showed no signs of ST-segment elevations or Q-wave development. Coronary angiography revealed a proximal thrombotic occlusion of the left anterior descending coronary artery. Successful recanalization, after thrombus aspiration and balloon dilation followed by stent implant, was verified with normalized anterograde flow. Immediately after the patient's arrival in the intensive cardiac care unit, a drop in her blood pressure to 60/30 mmHg and a hemoglobin concentration of 4.5 g/dl were noticed. Transfusion was started, and bedside abdominal ultrasound examination revealed free intraperitoneal fluid. Computed tomography of the abdomen revealed liver injury with active extravasation from the cranial surface of the right lobe and a massive hemoperitoneum. The patient was coagulopathic and acidotic with a body temperature of 33.5 °C. A minimally invasive treatment strategy, including angiography and selective trans-catheter arterial embolization, were performed in combination with percutaneous evacuation of 4.5 L of intraperitoneal blood. After completion of these procedures, the patient was hemodynamically stable. She was weaned off mechanical ventilation 2 days later and made an uneventful recovery. She was discharged to a local hospital on day 13 without neurological disability.", + "summary_subclaims": [ + "The patient was a 37-year-old white woman.", + "The patient was admitted after out-of-hospital cardiac arrest.", + "Bystander cardiopulmonary resuscitation was immediately performed.", + "Advanced cardiopulmonary resuscitation included tracheal intubation.", + "Advanced cardiopulmonary resuscitation included mechanical chest compressions.", + "Advanced cardiopulmonary resuscitation included external defibrillation.", + "Return of spontaneous circulation occurred.", + "Upon hospital admission, the patient's blood pressure was 94/45 mmHg.", + "Upon hospital admission, the patient's heart rate was 110 beats per minute.", + "The electrocardiogram showed no signs of ST-segment elevations.", + "The electrocardiogram showed no signs of Q-wave development.", + "Coronary angiography revealed a proximal thrombotic occlusion of the left anterior descending coronary artery.", + "Successful recanalization was verified with normalized anterograde flow.", + "The recanalization was achieved after thrombus aspiration.", + "The recanalization was achieved after balloon dilation.", + "The recanalization was achieved after stent implant.", + "A drop in blood pressure to 60/30 mmHg was noticed.", + "A hemoglobin concentration of 4.5 g/dl was noticed.", + "Transfusion was started.", + "Bedside abdominal ultrasound examination revealed free intraperitoneal fluid.", + "Computed tomography of the abdomen revealed liver injury with active extravasation from the cranial surface of the right lobe.", + "Computed tomography of the abdomen revealed a massive hemoperitoneum.", + "The patient was coagulopathic.", + "The patient was acidotic.", + "The patient's body temperature was 33.5 °C.", + "A minimally invasive treatment strategy was performed.", + "Angiography and selective trans-catheter arterial embolization were performed.", + "Percutaneous evacuation of 4.5 L of intraperitoneal blood was performed.", + "After completion of these procedures, the patient was hemodynamically stable.", + "The patient was weaned off mechanical ventilation 2 days later.", + "The patient made an uneventful recovery.", + "The patient was discharged to a local hospital on day 13.", + "The patient was discharged without neurological disability." + ] + }, + { + "id": "multiclinsum_test_2067_en.txt", + "fulltext": "A 66-year-old man was admitted to the clinic of a primary care doctor complaining of a sudden deterioration in right hypochondoralgia persisting for 2 weeks. A computed tomography (CT) scan revealed a right adrenal hemorrhage and an abnormal tumor in the upper lobe of his left lung. He was subsequently referred to our hospital for further examination and treatment.\nHis past medical history and family history were unremarkable. He was a current smoker with a history of 46 pack-years. An enhanced CT scan showed a massive shadow in the left lung S1 + 2 progressing to S6 beyond the lung lobe, with a maximum diameter of about 42 mm , and a right adrenal hematoma with no active bleeding . The laboratory data revealed a slight elevation in carcinoembryonic antigen (CEA, 5.6 ng/mL) and neuron-specific enolase (NSE, 18.52 ng/mL). The patient had mild anemia (hemoglobin, 10.3 g/dL).\nA diagnosis of the pulmonary lesion using a bronchoscopic trans-bronchial lung biopsy showed no evidence of malignancy; therefore, a CT-guided percutaneous needle biopsy was performed. The pathological examination showed a non-small cell lung cancer (NSCLC) that was suspected to be a pleomorphic carcinoma. The adrenal lesion was diagnosed as a nonfunctional tumor based on endocrine examinations and adrenal medulla scintigraphy (123I-MIBG). 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed the accumulation of FDG not only in the left lung nodule (SUVmax, 17.0) but also in the right adrenal one (SUVmax, 4.1) . Together, these results suggested a diagnosis of NSCLC and adrenal metastasis, and the clinical stage was classified as cT2bN0M1b, stage IV (TNM classification 7th edition).\nBecause there was a risk of rebleeding from adrenal metastasis, we performed a right adrenalectomy. We considered that a complete resection of the primary lung cancer would be possible since the adrenal metastasis was an oligometastasis. A pathological analysis of the lung tumor demonstrated areas of atypical cells with eosinophilic cytoplasms as well as sarcomatous component, with extensive necrosis . Immunohistochemistry revealed that the tumor cells were positive for cytokeratin AE1/3, CAM5.2, CK7, and p63 (partial) but negative for 34βE12, CK20, TTF-1, calretinin, and D2-40. The adrenal tumor was similar in pathologic and immunohistochemical analyses . Thus, the final diagnosis was pleomorphic carcinoma of the lung with an adrenal metastasis, pT2bN0M1b, stage IV (TNM classification 7th edition).\nThe patient received chemotherapy as stage IV NSCLC (60 mg/m2 of cisplatin on day 1 and 40 mg/m2 of TS-1 twice a day on days 1 to 14, repeated every 4 weeks). After two courses, he decided to quit the intravenous chemotherapy because of adverse events, general malaise, and anorexia. We suggested to receive oral chemotherapy, but he refused to take TS-1 because he feared adverse events. Consequently, he began taking UFT (600 mg/day) and continued this treatment for 2 years. He has survived without any recurrences for 6 years since the surgery.", + "fulltext_subclaims": [ + "A 66-year-old man was admitted to the clinic of a primary care doctor.", + "He complained of a sudden deterioration in right hypochondrial pain persisting for 2 weeks.", + "A computed tomography (CT) scan revealed a right adrenal hemorrhage.", + "A computed tomography (CT) scan revealed an abnormal tumor in the upper lobe of his left lung.", + "He was referred to our hospital for further examination and treatment.", + "His past medical history and family history were unremarkable.", + "He was a current smoker with a history of 46 pack-years.", + "An enhanced CT scan showed a massive shadow in the left lung S1 + 2 progressing to S6 beyond the lung lobe.", + "The maximum diameter of the left lung lesion was about 42 mm.", + "The right adrenal lesion showed no active bleeding.", + "The carcinoembryonic antigen (CEA) was 5.6 ng/mL.", + "The neuron-specific enolase (NSE) was 18.52 ng/mL.", + "The patient had mild anemia with a hemoglobin of 10.3 g/dL.", + "A bronchoscopic trans-bronchial lung biopsy showed no evidence of malignancy.", + "A CT-guided percutaneous needle biopsy was performed.", + "The pathological examination showed a non-small cell lung cancer.", + "The adrenal lesion was diagnosed as a nonfunctional tumor based on endocrine examinations and adrenal medulla scintigraphy.", + "18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG accumulation in the left lung nodule with an SUVmax of 17.0.", + "18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG accumulation in the right adrenal lesion with an SUVmax of 4.1.", + "The clinical stage was classified as cT2bN0M1b, stage IV (TNM classification 7th edition).", + "A right adrenalectomy was performed.", + "A complete resection of the primary lung cancer was considered possible.", + "The lung tumor showed areas of atypical cells with eosinophilic cytoplasms.", + "The lung tumor showed a sarcomatous component with extensive necrosis.", + "The tumor cells were positive for cytokeratin AE1/3, CAM5.2, CK7, and p63 (partial).", + "The tumor cells were negative for 34βE12, CK20, TTF-1, calretinin, and D2-40.", + "The adrenal tumor was similar in pathologic and immunohistochemical analyses.", + "The final diagnosis was pleomorphic carcinoma of the lung with an adrenal metastasis, pT2bN0M1b, stage IV (TNM classification 7th edition).", + "The patient received chemotherapy as stage IV NSCLC.", + "The chemotherapy regimen included 60 mg/m2 of cisplatin on day 1.", + "The chemotherapy regimen included 40 mg/m2 of TS-1 twice a day on days 1 to 14.", + "The chemotherapy regimen was repeated every 4 weeks.", + "After two courses, he decided to quit the intravenous chemotherapy.", + "He refused to take TS-1 because he feared adverse events.", + "He began taking UFT (600 mg/day).", + "He continued UFT treatment for 2 years.", + "He has survived without any recurrences for 6 years since the surgery." + ], + "summary": "We present a case of stage IV pleomorphic carcinoma; the patient was a 66-year-old male. He was referred to our hospital because of a right adrenal hemorrhage and a lung tumor. A systemic examination revealed that the lung tumor was a primary lung cancer and that the adrenal hemorrhage was due to a metastatic cancer. We performed an adrenalectomy and resection of the lung tumor and obtained a diagnosis of pleomorphic carcinoma with adrenal metastasis. The patient has remained recurrence-free for 6 years since the surgery.", + "summary_subclaims": [ + "The patient was a 66-year-old male.", + "The patient was referred to the hospital because of a right adrenal hemorrhage.", + "The patient was referred to the hospital because of a lung tumor.", + "The lung tumor was a primary lung cancer.", + "The adrenal hemorrhage was due to a metastatic cancer.", + "An adrenalectomy was performed.", + "Resection of the lung tumor was performed.", + "The diagnosis was pleomorphic carcinoma with adrenal metastasis.", + "The patient has remained recurrence-free for 6 years since the surgery." + ] + }, + { + "id": "multiclinsum_test_367_en.txt", + "fulltext": "A 44-year-old Japanese woman, gravida 3 para 3, who had undergone cesarean section 2 years previously, presented to our emergency room with a 2-day history of intermittent right flank pain. She had no fever, nausea, vomiting, diarrhea, or cough. She had no history of abdominal trauma, and her past medical history and family history were not significant. She did not have hypertension or cardiovascular disease, and had not taken any anticoagulants. Her bowel and urinary habits were normal, and her menstrual periods were regular. Her last menstrual period had begun 2 days before the onset of right flank pain. On admission, her blood pressure was 115/78 mmHg, pulse 70 beats per minute, body temperature 36°C, and blood oxygen saturation 100%. She was found to be somewhat anemic, with a hemoglobin concentration of 9.8 g/dL and hematocrit of 28.2%. Her white blood cell count was elevated (13,900/mm3), and a urine pregnancy test was negative.\nOn physical examination, her abdomen was diffusely tender without muscle guarding. A pelvic examination revealed a small amount of menstrual discharge and a normal uterus and bilateral adnexae. Abdominal ultrasonography demonstrated a large retroperitoneal hematoma surrounding her right kidney . Emergent abdominal and pelvic computed tomography (CT) was performed. Contrast-enhanced dynamic CT revealed a large retroperitoneal hematoma surrounding her right kidney with an enhancing round structure in the center of the hematoma in the arterial phase . Although extravasation in the venous phase was not clear, findings on three-dimensional CT angiography were suggestive of a retroperitoneal hematoma due to rupture of an aneurysm of her right ovarian artery , and no other responsible lesion was seen. A transfemoral angiography was performed for arterial embolization under a clinical diagnosis of bleeding from a right ovarian artery aneurysm. A selective angiogram of her right ovarian artery revealed a tortuous aneurysm near its origin from the aorta without obvious active extravasation . A 2.1-Fr microcatheter (Tangent™; Boston Scientific, USA) was advanced into the orifice of the aneurysm, and 1mL of 16.7% N-butyl-2-cyanoacrylate (NBCA) diluted in iodized oil (Lipiodol®; Guerbet Japan, Tokyo, Japan) was manually injected beyond the distal site of the aneurysm. A postembolization angiogram showed complete occlusion of the vessel . No other aneurysm was found on three-dimensional CT and angiography.\nOne day after TAE, CT was performed, which showed that the hematoma had decreased in size, and there was no sign of extravasation. In addition, her hemoglobin and hematocrit were found to have dropped to 7.9 g/dL and 24.1%, respectively. She was administered iron for 4 days, with a subsequent increase in hemoglobin and hematocrit to 8.9g/dL and 25.6%, respectively. No other surgical intervention was needed, and her course after embolization was uneventful. She was discharged on the fifth hospital day, and has remained symptom-free during 3 months of follow-up.", + "fulltext_subclaims": [ + "The patient is a 44-year-old Japanese woman.", + "She had undergone cesarean section 2 years previously.", + "She presented with a 2-day history of intermittent right flank pain.", + "She had no fever, nausea, vomiting, diarrhea, or cough.", + "Her past medical history and family history were not significant.", + "She did not have hypertension or cardiovascular disease.", + "Her last menstrual period had begun 2 days before the onset of right flank pain.", + "On admission, her blood pressure was 115/78 mmHg.", + "Her hemoglobin concentration was 9.8 g/dL.", + "Her white blood cell count was 13,900/mm3.", + "A urine pregnancy test was negative.", + "Abdominal ultrasonography demonstrated a large retroperitoneal hematoma surrounding her right kidney.", + "Contrast-enhanced dynamic CT revealed a large retroperitoneal hematoma surrounding her right kidney with an enhancing round structure in the center of the hematoma in the arterial phase.", + "Findings on three-dimensional CT angiography were suggestive of a retroperitoneal hematoma due to rupture of an aneurysm of her right ovarian artery.", + "A transfemoral angiography was performed for arterial embolization under a clinical diagnosis of bleeding from a right ovarian artery aneurysm.", + "A selective angiogram of her right ovarian artery revealed a tortuous aneurysm near its origin from the aorta without obvious active extravasation.", + "A 2.1-Fr microcatheter was advanced into the orifice of the aneurysm.", + "1mL of 16.7% N-butyl-2-cyanoacrylate diluted in iodized oil was manually injected beyond the distal site of the aneurysm.", + "A postembolization angiogram showed complete occlusion of the vessel.", + "One day after TAE, CT showed that the hematoma had decreased in size.", + "Her hemoglobin and hematocrit dropped to 7.9 g/dL and 24.1%, respectively.", + "She was administered iron for 4 days.", + "Her hemoglobin and hematocrit increased to 8.9g/dL and 25.6%, respectively.", + "No other surgical intervention was needed.", + "She was discharged on the fifth hospital day.", + "She has remained symptom-free during 3 months of follow-up." + ], + "summary": "A 44-year-old Japanese woman, gravida 3 para 3, presented to our emergency room complaining of intermittent right flank pain. She had undergone a cesarean section 2 years previously, and had no history of abdominal trauma. On admission, her blood pressure was 115/78 mmHg, pulse 70 beats per minute, and hemoglobin concentration 9.8 g/dL. Abdominal ultrasonography and contrast-enhanced dynamic computed tomography revealed a large retroperitoneal hematoma. Findings on three-dimensional computed tomography angiography suggested ruptured aneurysm of her right ovarian artery. A selective right ovarian artery angiogram revealed a tortuous aneurysm. Transcatheter arterial embolization using N-butyl-2-cyanoacrylate was performed. The aneurysm was successfully embolized, and her course after embolization was uneventful. She has remained symptom-free during 3 months of follow-up.", + "summary_subclaims": [ + "The patient is a 44-year-old Japanese woman.", + "She is gravida 3 para 3.", + "She presented to the emergency room with intermittent right flank pain.", + "She had undergone a cesarean section 2 years previously.", + "She had no history of abdominal trauma.", + "On admission, her blood pressure was 115/78 mmHg.", + "On admission, her pulse was 70 beats per minute.", + "On admission, her hemoglobin concentration was 9.8 g/dL.", + "Abdominal ultrasonography and contrast-enhanced dynamic computed tomography revealed a large retroperitoneal hematoma.", + "Findings on three-dimensional computed tomography angiography suggested ruptured aneurysm of the right ovarian artery.", + "A selective right ovarian artery angiogram revealed a tortuous aneurysm.", + "Transcatheter arterial embolization using N-butyl-2-cyanoacrylate was performed.", + "The aneurysm was successfully embolized.", + "Her course after embolization was uneventful.", + "She has remained symptom-free during 3 months of follow-up." + ] + }, + { + "id": "multiclinsum_test_2143_en.txt", + "fulltext": "A 15-year-old female presented with three months of lower back pain radiating into her bilateral posterior thighs and knees. She had no history of trauma, infection, connective tissue disease, or previous spine condition. She had no weakness in her upper and lower extremities, bowel or bladder incontinence, saddle anesthesia, or difficulty ambulating. Twice daily ibuprofen and physical therapy for two months did not improve or resolve her symptoms. Thoracic and lumbar spine magnetic resonance imaging (MRI) demonstrated a large dorsal extradural meningeal cyst at T11–L2 with associated neural foraminal extension and bony expansion . Imaging also showed ventral displacement and compression of the distal spinal cord and nerve roots of the cauda equina. On imaging, there is a flow void noted at L1 on the left side, thought to be the site of a dural defect leading to the cyst . The patient’s bilateral lower extremity symptoms were due to the extension of the large cyst into the bilateral neuroforamina from T11 to L2 and associated ventral compression and displacement of the distal spinal cord and cauda equina nerve roots.\nInstead of a traditional approach with multi-level laminectomy and given the identification of the likely site of the dural defect at L1, a minimally invasive approach in the form of L1–L2 laminectomy, fenestration of the arachnoid cyst, and L1 dural defect repair was selected to reduce the potential morbidity associated with a more extensive approach. Intraoperatively, the extradural cyst wall was located dorsally . A microdissection of the cyst was completed. A portion of the cyst wall was bipolared, cut and removed and sent to pathology for the permanent specimen. A dural defect at the L1 nerve root was confirmed . Primary repair was not possible as the dural edges were too far apart, and the dural opening was near the axilla of the nerve root. The secondary repair was completed by sealing the dural defect with a fibrin sealant, harvesting the fascial graft, and adding another layer of fibrin sealant. Valsalva demonstrated no evidence of a CSF leak, and the incision was closed in standard fashion. Histological findings of the spinal cyst wall showed benign fibrovascular tissue, consistent with a spinal arachnoid cyst.\nThe patient had an uneventful postoperative period. Repeat imaging four months postoperatively demonstrated no residual extradural meningeal cyst . The patient’s lower back pain, bilateral thigh pain, and paresthesias completely resolved.", + "fulltext_subclaims": [ + "The patient is a 15-year-old female.", + "She had three months of lower back pain radiating into her bilateral posterior thighs and knees.", + "She had no history of trauma.", + "She had no history of infection.", + "She had no history of connective tissue disease.", + "She had no history of previous spine condition.", + "She had no weakness in her upper and lower extremities.", + "She had no bowel or bladder incontinence.", + "She had no saddle anesthesia.", + "She had no difficulty ambulating.", + "Twice daily ibuprofen and physical therapy for two months did not improve or resolve her symptoms.", + "Thoracic and lumbar spine MRI demonstrated a large dorsal extradural meningeal cyst at T11–L2.", + "Imaging showed ventral displacement and compression of the distal spinal cord.", + "Imaging showed compression and displacement of the cauda equina nerve roots.", + "There is a flow void noted at L1 on the left side.", + "The flow void is thought to be the site of a dural defect leading to the cyst.", + "The patient’s bilateral lower extremity symptoms were due to the extension of the large cyst into the bilateral neuroforamina from T11 to L2.", + "The patient’s bilateral lower extremity symptoms were due to ventral compression and displacement of the distal spinal cord and cauda equina nerve roots.", + "A minimally invasive approach in the form of L1–L2 laminectomy, fenestration of the arachnoid cyst, and L1 dural defect repair was selected.", + "The extradural cyst wall was located dorsally.", + "A microdissection of the cyst was completed.", + "A portion of the cyst wall was bipolared, cut and removed and sent to pathology.", + "A dural defect at the L1 nerve root was confirmed.", + "Primary repair was not possible.", + "The secondary repair was completed by sealing the dural defect with a fibrin sealant.", + "The secondary repair included harvesting the fascial graft.", + "The secondary repair included adding another layer of fibrin sealant.", + "Valsalva demonstrated no evidence of a CSF leak.", + "The incision was closed in standard fashion.", + "Histological findings of the spinal cyst wall showed benign fibrovascular tissue.", + "Histological findings were consistent with a spinal arachnoid cyst.", + "Repeat imaging four months postoperatively demonstrated no residual extradural meningeal cyst.", + "The patient’s lower back pain completely resolved.", + "The patient’s bilateral thigh pain completely resolved.", + "The patient’s paresthesias completely resolved." + ], + "summary": "Here, we present a case of a 15-year-old female who presented with lower back pain radiating to her bilateral posterior thighs and knees, with imaging indicating a thoracolumbar spinal extradural arachnoid cyst. After failed conservative treatment, surgical intervention in the form of laminectomy, fenestration of the arachnoid cyst, and repair of the dural defect was required, resolving the patient's symptoms with no recurrence of the cyst.", + "summary_subclaims": [ + "The patient is a 15-year-old female.", + "The patient presented with lower back pain radiating to her bilateral posterior thighs and knees.", + "Imaging indicated a thoracolumbar spinal extradural arachnoid cyst.", + "Conservative treatment failed.", + "Surgical intervention was required.", + "The surgical intervention included laminectomy.", + "The surgical intervention included fenestration of the arachnoid cyst.", + "The surgical intervention included repair of the dural defect.", + "The patient's symptoms were resolved.", + "There was no recurrence of the cyst." + ] + }, + { + "id": "multiclinsum_test_3346_en.txt", + "fulltext": "A 41-year-old Inuit female complaining of blurred vision in the left eye was referred to our eye department. The patient’s past medical history included diabetes mellitus type 2, arterial hypertension and hypercholesterolemia. The patient had no past ocular history and there was no sign of diabetic retinopathy during diabetic eye screening six months prior, although a possible area of neovascularization was found in the right eye that could not be attributed to diabetes. In retrospect, this area of possible neovascularization may have been an early sign of Eales’ disease: the patient had received antibiotic treatment for TB in 2010 following a positive QuantiFERON® test. Telemedical assessment including ultra wide-field fundus imaging could neither confirm nor deny a specific diagnosis, but images were suspicious for vitritis or vitreous hemorrhage in the right eye. Eales’ disease could not be ruled out, and the patient was flown from Greenland to Denmark for further evaluation, including investigation of the cause of her suspected vitreoretinopathy. Arrangements were made for the patient to stay at the Greenland patient hotel in Copenhagen for the duration of her treatment.\n\nResults\nOn examination, visual acuity was 6/12 in the right eye and 6/36 in the left eye (Snellen). Fundoscopy revealed mild vitritis in the right eye, a vitreous hemorrhage in the left eye with neovascularization of the disc in the left eye and retinal neovascularization elsewhere in both eyes. Fundus fluorescein angiography showed vessel leakage and areas of non-perfusion in the retinal mid-peripheries. There was left epiretinal membrane with retinal thickening on macular optical coherence tomography.\n\nEales’ disease is an occlusive vasculitis involving the retinal mid-periphery that commonly presents with vitreous hemorrhage. It is further characterized by periphlebitis, vascular occlusion and subsequent retinal neovascularization. Based on the patient findings and history of TB infection in this case, a diagnosis of Eales’ disease was made. The patient’s epiretinal membrane was thought to be visually significant, leading to treatment of the left eye with pars plana vitrectomy with epiretinal membrane peeling, endodiathermy and endolaser. The right eye was treated in outpatients with sectoral laser photocoagulation. At seven weeks’ follow-up, the visual acuity had improved to 6/6 (right eye) and 6/7.5 (left eye). The patient had met with the visual acuity requirement for driving-licence vision in either eye and both eyes were deemed to be sufficiently treated.", + "fulltext_subclaims": [ + "The patient is a 41-year-old Inuit female.", + "The patient was referred to the eye department due to blurred vision in the left eye.", + "The patient’s past medical history includes diabetes mellitus type 2.", + "The patient’s past medical history includes arterial hypertension.", + "The patient’s past medical history includes hypercholesterolemia.", + "The patient had no past ocular history.", + "A possible area of neovascularization was found in the right eye during diabetic eye screening six months prior.", + "The area of possible neovascularization could not be attributed to diabetes.", + "In retrospect, the area of possible neovascularization may have been an early sign of Eales’ disease.", + "The patient had received antibiotic treatment for TB in 2010.", + "The TB treatment followed a positive QuantiFERON® test.", + "Telemedical assessment could neither confirm nor deny a specific diagnosis.", + "Images were suspicious for vitritis or vitreous hemorrhage in the right eye.", + "Eales’ disease could not be ruled out.", + "The patient was flown from Greenland to Denmark for further evaluation.", + "The patient was to stay at the Greenland patient hotel in Copenhagen.", + "On examination, visual acuity was 6/12 in the right eye.", + "On examination, visual acuity was 6/36 in the left eye.", + "Fundoscopy revealed mild vitritis in the right eye.", + "Fundoscopy revealed a vitreous hemorrhage in the left eye.", + "Fundoscopy revealed neovascularization of the disc in the left eye.", + "Fundus fluorescein angiography showed vessel leakage.", + "Fundus fluorescein angiography showed areas of non-perfusion in the retinal mid-peripheries.", + "There was left epiretinal membrane with retinal thickening on macular optical coherence tomography.", + "Eales’ disease is an occlusive vasculitis involving the retinal mid-periphery.", + "Eales’ disease commonly presents with vitreous hemorrhage.", + "Eales’ disease is characterized by periphlebitis.", + "Eales’ disease is characterized by vascular occlusion.", + "Eales’ disease is characterized by retinal neovascularization.", + "A diagnosis of Eales’ disease was made based on the patient findings and history of TB infection.", + "The patient’s epiretinal membrane was thought to be visually significant.", + "The left eye was treated with pars plana vitrectomy with epiretinal membrane peeling.", + "The left eye was treated with endodiathermy.", + "The left eye was treated with endolaser.", + "The right eye was treated with sectoral laser photocoagulation.", + "At seven weeks’ follow-up, visual acuity had improved to 6/6 in the right eye.", + "At seven weeks’ follow-up, visual acuity had improved to 6/7.5 in the left eye.", + "The patient had met the visual acuity requirement for driving-licence vision in either eye.", + "Both eyes were deemed to be sufficiently treated." + ], + "summary": "A 41-year-old Inuit female complaining of blurred vision was referred to our eye department. There had been no sign of diabetic retinopathy during diabetic eye screening and the patient had been treated for tuberculosis in 2010. Telemedical assessment was suspicious for vitritis or vitreous hemorrhage in the right eye, and the patient was flown from Greenland to Denmark, where examination revealed mild vitritis in the right eye, vitreous hemorrhage in the left eye and retinal neovascularization in both eyes. Fundus fluorescein angiography showed vessel leakage and areas of retinal non-perfusion. There was left epiretinal membrane with retinal thickening on macular optical coherence tomography.", + "summary_subclaims": [ + "The patient is a 41-year-old Inuit female.", + "The patient complained of blurred vision.", + "The patient was referred to the eye department.", + "There had been no sign of diabetic retinopathy during diabetic eye screening.", + "The patient had been treated for tuberculosis in 2010.", + "Telemedical assessment was suspicious for vitritis or vitreous hemorrhage in the right eye.", + "The patient was flown from Greenland to Denmark.", + "Examination revealed mild vitritis in the right eye.", + "Examination revealed vitreous hemorrhage in the left eye.", + "Examination revealed retinal neovascularization in both eyes.", + "Fundus fluorescein angiography showed vessel leakage.", + "Fundus fluorescein angiography showed areas of retinal non-perfusion.", + "There was left epiretinal membrane.", + "There was retinal thickening on macular optical coherence tomography." + ] + }, + { + "id": "multiclinsum_test_3261_en.txt", + "fulltext": "A 78-year-old man presented to our Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto, complaining a progressive bilateral decreased vision, repeated episodes of sudden onset of pain with redness, and foreign body sensation. Concerning ophthalmic history, he underwent previously conventional phacoemulsification with IOL implantation in both eyes, and trabeculectomy in right eye (RE). He was under topic antiglaucoma therapy in both eyes. His visual acuity was 20/100 in RE and 20/400 in the left eye (LE). Slit lamp examination revealed corneal erosions and relevant stromal opacities with branching lines in the inferior portion of the cornea of both eyes. The lesions spared the peripheral cornea and did not involve the limbus. No other pathological findings were observed. Ophthalmological examination of the family members of our patient revealed similar clinical findings in the patient’s daughter and son, supporting the diagnosis of RCEs in LCD with an autosomal dominant inheritance.\n\nThe Institutional Review Board (IRB) of the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto approved the study protocol. All clinical procedures were conducted according to the principles of the Declaration of Helsinki. The patient provided informed consent for all procedures and their possible complications were explained. The patient gave informed consent for the publication of any case details and accompanying images. The IRB of the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto gave the approval for the publication of this case report.\n\nOur first attempt was using autologous serum drops four times daily with no improvement at all.9 A treatment with amniotic membrane extract eye drops (AMEED) was started.10 Even in this case, the improvement in symptoms was temporary with no effect on the corneal opacities. The patient was subsequently placed under nerve growth factor (NGF) eye drops q.i.d.11 After a few days, there was an improvement in symptoms. After one month of treatment, the patient was uncomfortable, complaining again foreign body sensation. The slit lamp examination showed corneal epithelium irregularities, RCEs, and stromal opacities.\n\nThe combined treatment with PRK and PTK was scheduled in both eyes, firstly in the LE and, after 2 weeks in the RE. A trans-epithelial topography-guided approach using the iRes® excimer laser platform (iVIS Technologies, Taranto, Italy) was performed under topical oxibuprocaine anesthesia.\n\nThe customized treatment was based on refractive and morphological data including spherical error collected by the visual acuity examination; biometric data including anterior chamber depth, intraocular lens (IOL) power, and axial length; corneal morphological irregularity index (CMI) measured by tomographer (Precisio2®, iVIS Technologies, Taranto, Italy); target refractive zone and ablation zone defined by the projection of an ideal pupil, identified by dynamic pupillometry (pMetrics®, iVIS Technologies, Taranto, Italy), onto the ideal corneal surface. The Corneal Interactive Programmed Topographic Ablation software (CIPTA®, iVIS Technologies, Taranto, Italy) determined the volume of ablation as the intersection between the anterior shape detected by the tomographer and the ideal shape determined taking care of the total corneal astigmatism and of the high order of aberrations, by means of a ray tracing process.\n\nThe customized ablation profile obtained with PRK, had a refractive zone of 5.00 mm in RE and 3.8 mm in LE, and a connecting zone of 8.80 mm in RE and 9.1 mm in LE. The cumulative ablation depth was 34 μm in the RE and 90 μm in the LE. After surface ablation, PTK was performed using masking agents (1% hydroxy-methylcellulose) to smooth the ablated surface. Subsequently, 0.02% Mitomycin C (MMC, 0.2 mg/mL, diluted in BSS®) was applied over the ablated surface for a duration of 20 seconds. At the end of the procedure, a soft therapeutic contact lens was placed.\n\nPostoperatively, topical dexamethasone and amikacin eye drops were administered four times daily for one week. The patient was then put on 0.1% fluorometholone eye drops and artificial tears eye drops for 12 weeks, which were gradually tapered afterward. The contact lens was removed after 1 week. At the 3-month follow-up, a slit lamp examination revealed a clear central cornea in both eyes.\n\nThe final visual acuity improved to 20/25 in the RE and 20/50 in the LE at 3 months after treatment. The keratometric astigmatism improved from −1.71 D to −0.92 D in RE, and from −5.43 D to −1.12 D in LE. CMI decreased from 16.04 µm to 7.84 µm in RE and from 53.07 µm to 37.04 µm in LE, and minimum corneal thickness was reduced from 570 µm to 508 µm in RE, and from 576 µm to 452 µm in LE. The postoperative follow-up was uneventful. The ablation map and topographic changes of both eyes were reported.", + "fulltext_subclaims": [ + "A 78-year-old man presented to the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto.", + "He complained of progressive bilateral decreased vision.", + "He had repeated episodes of sudden onset of pain with redness.", + "He had a foreign body sensation.", + "He had previously undergone conventional phacoemulsification with IOL implantation in both eyes.", + "He had previously undergone trabeculectomy in the right eye.", + "He was under topic antiglaucoma therapy in both eyes.", + "His visual acuity was 20/100 in the right eye.", + "His visual acuity was 20/400 in the left eye.", + "Slit lamp examination revealed corneal erosions in both eyes.", + "Slit lamp examination revealed relevant stromal opacities with branching lines in the inferior portion of the cornea of both eyes.", + "The lesions spared the peripheral cornea.", + "The lesions did not involve the limbus.", + "Ophthalmological examination of the family members revealed similar clinical findings in the patient’s daughter and son.", + "The diagnosis was RCEs in LCD with an autosomal dominant inheritance.", + "The Institutional Review Board of the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto approved the study protocol.", + "The patient provided informed consent for all procedures.", + "The patient gave informed consent for the publication of any case details and accompanying images.", + "The IRB of the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto gave the approval for the publication of this case report.", + "The first attempt used autologous serum drops four times daily.", + "There was no improvement with autologous serum drops.", + "A treatment with amniotic membrane extract eye drops was started.", + "The improvement in symptoms with amniotic membrane extract eye drops was temporary.", + "There was no effect on the corneal opacities with amniotic membrane extract eye drops.", + "The patient was placed under nerve growth factor eye drops q.i.d.", + "After a few days, there was an improvement in symptoms.", + "After one month of treatment, the patient was uncomfortable.", + "The patient complained again of foreign body sensation.", + "The slit lamp examination showed corneal epithelium irregularities.", + "The slit lamp examination showed RCEs.", + "The slit lamp examination showed stromal opacities.", + "The combined treatment with PRK and PTK was scheduled in both eyes.", + "The combined treatment was scheduled first in the left eye.", + "The combined treatment was scheduled in the right eye after 2 weeks.", + "A trans-epithelial topography-guided approach using the iRes® excimer laser platform was performed.", + "The customized treatment was based on refractive and morphological data.", + "The customized treatment was based on spherical error collected by the visual acuity examination.", + "The customized treatment was based on biometric data including anterior chamber depth.", + "The customized treatment was based on biometric data including intraocular lens power.", + "The customized treatment was based on biometric data including axial length.", + "The customized treatment was based on the corneal morphological irregularity index measured by tomographer.", + "The customized treatment was based on the target refractive zone defined by the projection of an ideal pupil.", + "The customized treatment was based on the ablation zone defined by the projection of an ideal pupil.", + "The Corneal Interactive Programmed Topographic Ablation software determined the volume of ablation.", + "The customized ablation profile obtained with PRK had a refractive zone of 5.00 mm in the right eye.", + "The customized ablation profile obtained with PRK had a refractive zone of 3.8 mm in the left eye.", + "The customized ablation profile obtained with PRK had a connecting zone of 8.80 mm in the right eye.", + "The customized ablation profile obtained with PRK had a connecting zone of 9.1 mm in the left eye.", + "The cumulative ablation depth was 34 μm in the right eye.", + "The cumulative ablation depth was 90 μm in the left eye.", + "After surface ablation, PTK was performed using masking agents.", + "0.02% Mitomycin C was applied over the ablated surface for a duration of 20 seconds.", + "A soft therapeutic contact lens was placed.", + "Postoperatively, topical dexamethasone and amikacin eye drops were administered four times daily for one week.", + "The patient was put on 0.1% fluorometholone eye drops and artificial tears eye drops for 12 weeks.", + "The contact lens was removed after 1 week.", + "At the 3-month follow-up, a slit lamp examination revealed a clear central cornea in both eyes.", + "The final visual acuity improved to 20/25 in the right eye.", + "The final visual acuity improved to 20/50 in the left eye.", + "The keratometric astigmatism improved from −1.71 D to −0.92 D in the right eye.", + "The keratometric astigmatism improved from −5.43 D to −1.12 D in the left eye.", + "CMI decreased from 16.04 µm to 7.84 µm in the right eye.", + "CMI decreased from 53.07 µm to 37.04 µm in the left eye.", + "Minimum corneal thickness was reduced from 570 µm to 508 µm in the right eye.", + "Minimum corneal thickness was reduced from 576 µm to 452 µm in the left eye.", + "The postoperative follow-up was uneventful." + ], + "summary": "A 78-year-old man presented us with decreased visual acuity [20/100 in right eye (RE), and 20/400 in left eye (LE)], and redness with foreign body sensation in both eyes. Clinical examination revealed epithelial erosions, and linear stromal opacities involving the center of the cornea in both eyes, supporting the diagnosis of LCD. Several medical approaches including autologous serum, amniotic membrane extract, and nerve growth factor eye drops allowed a temporary improvement in symptoms. A single-step topography-guided trans-epithelial PRK combined with PTK (CIPTA®2 software, iVis Technologies) was performed in both eyes. After surface ablation using PRK, PTK was performed using masking agents (1% hydroxy-methylcellulose) to smooth the ablated surface. Subsequently, 0.02% Mitomycin C was applied over the ablated surface. At the 3-month follow-up, a resolution of corneal erosions, and stromal opacities were observed in both eyes, with a visual improvement to 20/25 in the RE and 20/50 in the LE. Furthermore, spherical equivalent, keratometric astigmatism, and corneal morphological irregularity index improved.", + "summary_subclaims": [ + "The patient is a 78-year-old man.", + "The patient had decreased visual acuity.", + "The visual acuity was 20/100 in the right eye.", + "The visual acuity was 20/400 in the left eye.", + "The patient had redness with foreign body sensation in both eyes.", + "Clinical examination revealed epithelial erosions.", + "Linear stromal opacities involving the center of the cornea were observed in both eyes.", + "The diagnosis was LCD.", + "Medical approaches included autologous serum.", + "Medical approaches included amniotic membrane extract.", + "Medical approaches included nerve growth factor eye drops.", + "A single-step topography-guided trans-epithelial PRK combined with PTK was performed in both eyes.", + "The procedure used the CIPTA®2 software.", + "Surface ablation was performed using PRK.", + "PTK was performed using masking agents.", + "1% hydroxy-methylcellulose was used as a masking agent.", + "0.02% Mitomycin C was applied over the ablated surface.", + "At the 3-month follow-up, corneal erosions resolved in both eyes.", + "Stromal opacities resolved in both eyes.", + "Visual acuity improved to 20/25 in the right eye.", + "Visual acuity improved to 20/50 in the left eye.", + "Spherical equivalent improved.", + "Keratometric astigmatism improved.", + "Corneal morphological irregularity index improved." + ] + }, + { + "id": "multiclinsum_test_19_en.txt", + "fulltext": "Our patient a 29-year-old right hand dominant male, who presented late, about 25 days after trauma following a motor vehicle accident, had been to multiple hospitals previously and then came to this institute. On examination, he had frank swelling and deformity over the wrist. There was marked tenderness over carpals and the anatomical snuff box. He was unable to move the wrist however retained limited flexion and extension of the fingers. There was no associated open wound and no distal neurovascular compromise and no other skeletal injury. After presenting to the emergency room, his fresh anteroposterior, lateral, and oblique view radiographs of the wrist were done which showed the dislocation of the lunate volarly with the classical spilled tea-cup sign suggestive of volar PLD. An attempt for closed reduction under analgesia and local anesthesia was given in the emergency room itself, however, was deemed unsuccessful. The patient was applied a long arm cast and was subjected to further investigations before being posted for surgery. CT of the right wrist was done which was suggestive of volar displacement of the lunate with undisplaced fracture of waist of scaphoid. After routine investigations, pre-anesthesia evaluation and taking informed consent patient was posted for surgery.\nPatient was posted for open reduction and reduction was achieved through dorsal approach. Incision was taken over the dorsal aspect of wrist and after retracting the extensor tendons and cutting through the extensor retinaculum, the wrist joint capsule was visualized. The joint capsule was cut open and the lunate bone was identified under C arm. Traction and manipulation were done and after manipulation with the help of k wire, the lunate was reduced to its original place. Reduction was confirmed under C arm and was deemed acceptable. The fracture of the scaphoid was identified and two percutaneous Kirschner’s wires were passed across the fracture site to hold the fragments in place after confirming the reduction, ligament repair was done. After confirming the reduction and the joint stability, the joint capsule was closed, retinaculum was sutured back, and closure was done. The k wires were cut and pin tract dressing was done and along arm thumb spica cast was applied. Two weeks later, the sutures were removed and the cast was removed and the cast was changed with a short arm thumb spica cast. At 8 weeks, the k wires were removed and the patient was started with rigorous hand physiotherapy. At 1-year follow-up, the active range of motion for active flexion was 75° and active extension up to 65° with a decrease in pronation and supination to 55°. Modified mayo wrist score of 76 indicates a good outcome.", + "fulltext_subclaims": [ + "The patient is a 29-year-old right hand dominant male.", + "He presented 25 days after trauma following a motor vehicle accident.", + "He had been to multiple hospitals previously.", + "He had frank swelling and deformity over the wrist.", + "There was marked tenderness over carpals and the anatomical snuff box.", + "He was unable to move the wrist.", + "He retained limited flexion and extension of the fingers.", + "There was no associated open wound.", + "There was no distal neurovascular compromise.", + "There was no other skeletal injury.", + "Radiographs showed dislocation of the lunate volarly.", + "The radiographs showed the classical spilled tea-cup sign.", + "The spilled tea-cup sign is suggestive of volar PLD.", + "An attempt for closed reduction under analgesia and local anesthesia was given.", + "The closed reduction was deemed unsuccessful.", + "A long arm cast was applied.", + "CT of the right wrist was done.", + "The CT was suggestive of volar displacement of the lunate.", + "The CT showed an undisplaced fracture of the waist of scaphoid.", + "The patient was posted for surgery.", + "Open reduction was achieved through a dorsal approach.", + "The incision was taken over the dorsal aspect of the wrist.", + "The extensor tendons were retracted.", + "The extensor retinaculum was cut.", + "The wrist joint capsule was visualized.", + "The joint capsule was cut open.", + "The lunate bone was identified under C arm.", + "Traction and manipulation were done.", + "K wire was used to help manipulate the lunate.", + "The lunate was reduced to its original place.", + "Reduction was confirmed under C arm.", + "Reduction was deemed acceptable.", + "The fracture of the scaphoid was identified.", + "Two percutaneous Kirschner’s wires were passed across the fracture site.", + "The fragments were held in place after confirming the reduction.", + "Ligament repair was done.", + "The joint capsule was closed.", + "The retinaculum was sutured back.", + "The k wires were cut.", + "Pin tract dressing was done.", + "A long arm thumb spica cast was applied.", + "Two weeks later, the sutures were removed.", + "The cast was changed with a short arm thumb spica cast.", + "At 8 weeks, the k wires were removed.", + "The patient was started with rigorous hand physiotherapy.", + "At 1-year follow-up, active flexion was 75°.", + "At 1-year follow-up, active extension was up to 65°.", + "Pronation and supination decreased to 55°.", + "The modified mayo wrist score was 76.", + "The modified mayo wrist score of 76 indicates a good outcome." + ], + "summary": "We have brought one such case where the patient, a 29-year-old male suffered a Transscaphoid PLFD, presented to us late and was treated with open reduction with good functional outcome postoperatively.", + "summary_subclaims": [ + "The patient was a 29-year-old male.", + "The patient suffered a Transscaphoid PLFD.", + "The patient presented to us late.", + "The patient was treated with open reduction.", + "The patient had a good functional outcome postoperatively." + ] + }, + { + "id": "multiclinsum_test_2949_en.txt", + "fulltext": "A 31-year-old pregnant woman gravida two abortion 1 admitted in our institution (HAZRAT ZEYNAB Hospital of Shiraz University of medical science) at gestational age (GA) of 27 + 3 weeks with the chief complaint of vaginal leakage and diagnosis of premature rupture of amniotic membrane (PROM). In her first obstetric sonography at GA of 19+2 weeks, the MCDA pattern was confirmed with adequate amniotic fluid, and no congenital anomalies were detected. On the first physical examination, no tachycardia, fever, and uterine tenderness were observed. The patient’s speculum examination revealed fern-positive vaginal leakage without malodor discharge, with a closed cervix and no uterine contraction. Ultrasound examination showed two alive fetuses, and the posterior placenta and amniotic fluid of both fetuses were adequate (5cm and 7.5cm). Strip NST of both fetuses was reactive with an FHR base of 150. Based on these examinations, the patient admitted and received IV antibiotics at first for two days, continued with oral antibiotics for seven days, and two doses of corticosteroids for lung maturation administered during 48hrs.\nThe patient was under observation in the hospital with weekly WBC and CRP (c-reactive protein) and twice-weekly NST and maternal pulse rate (PR) and temperature monitoring for early detection of chorioamnionitis signs. In-hospital course after two weeks of admission, the biometry and colorflowmetry of the umbilical artery revealed fetal weight discrepancy of 31% and IUGR stage I for one of the fetuses and the other fetus was relatively small for gestational age (SGA). Ultrasonography also reported that no intertwin membrane was seen most probably because of the rupture of the membrane since the patient had not experienced any invasive procedure during pregnancy. Fetal heart rate monitoring was acceptable for gestational age. Also, no sign of chorioamnionitis presented until the 3rd week of admission. At the 30th week of gestation, the patient developed maternal tachycardia (PR: 110-120), fever (t: 38-38.5), a rise in WBC count up to 14000, and persistent tachycardia of the IUGR fetus (170-180). Therefore after hydration and administration of broad-spectrum antibiotics, the emergency cesarean section was performed due to chorioamnionitis diagnosis. At the time of cesarean section two female newborns delivered by breech and vertex presentation, the first one cried immediately after birth with an APGAR score of 6, weighing 1430gr and the second one born with mild respiratory depression and poor APGAR score of 1 and birth weight of 1020gr. APGAR score re-evaluation five minutes after the delivery showed the scores of 8 and 6 for the first and the second newborn, respectively. Two times nuchal cord was observed around the neck of one of the fetuses. Furthermore, two umbilical cords were twisted and formed a complex of true knots and tight loops as it is shown in . Umbilical artery blood gas examinations showed PH: 7.4, pCo2: 35, HCO3: 21.3, base excess: -2.6, for the first fetus, and PH: 7.35, pCo2: 32, HCO3: 17.1 and base excess: -7, for the second one (the depressed baby). Both neonates were admitted in the NICU ward because of prematurity and also respiratory distress syndrome in the second twin. No significant neonatal complication occurred, except mild hyperbilirubinemia. All cultures and gram stain of throat, nose, blood, eye discharge, and CSF were negative. Brain sonography revealed grade-I IVH in the second twin. The first and the second babies were respectively discharged from NICU ward 20 and 24 days after their birth, and no complications have been observed yet in the afterbirth follow-ups. After consultation with the mother and upon her request, the placenta and umbilical cord were sent for histological examination. The anatomical pathology findings (macroscopic) confirmed the MCDA as the type of chorionicity with no specific pathological changes except cholangitis of the placenta.", + "fulltext_subclaims": [ + "A 31-year-old pregnant woman gravida two abortion 1 was admitted at 27 + 3 weeks gestation.", + "The patient's chief complaint was vaginal leakage.", + "The diagnosis was premature rupture of amniotic membrane.", + "In her first obstetric sonography at 19+2 weeks, the MCDA pattern was confirmed.", + "No congenital anomalies were detected in the first obstetric sonography.", + "On the first physical examination, no tachycardia, fever, or uterine tenderness were observed.", + "The patient’s speculum examination revealed fern-positive vaginal leakage.", + "The patient’s speculum examination showed no malodor discharge.", + "The patient’s speculum examination showed a closed cervix.", + "The patient’s speculum examination showed no uterine contraction.", + "Ultrasound showed two alive fetuses.", + "The posterior placenta and amniotic fluid of both fetuses were adequate.", + "Strip NST of both fetuses was reactive.", + "The FHR base of both fetuses was 150.", + "The patient received IV antibiotics for two days.", + "The patient received oral antibiotics for seven days.", + "Two doses of corticosteroids were administered within 48 hours.", + "The patient was under observation in the hospital.", + "Weekly WBC and CRP were monitored.", + "Twice-weekly NST was performed.", + "Maternal pulse rate and temperature were monitored.", + "After two weeks of admission, fetal weight discrepancy of 31% was noted.", + "IUGR stage I was diagnosed for one fetus.", + "The other fetus was small for gestational age.", + "Ultrasonography reported no intertwin membrane.", + "Fetal heart rate monitoring was acceptable for gestational age.", + "No sign of chorioamnionitis was present until the 3rd week of admission.", + "At 30 weeks of gestation, the patient developed maternal tachycardia.", + "At 30 weeks of gestation, the patient had a temperature of 38-38.5.", + "WBC count rose to 14000.", + "Persistent tachycardia of the IUGR fetus was noted.", + "Emergency cesarean section was performed due to chorioamnionitis diagnosis.", + "Two female newborns were delivered by breech and vertex presentation.", + "The first newborn cried immediately after birth.", + "The first newborn had an APGAR score of 6.", + "The first newborn weighed 1430 grams.", + "The second newborn had mild respiratory depression.", + "The second newborn had an APGAR score of 1.", + "The second newborn weighed 1020 grams.", + "Five-minute APGAR scores were 8 and 6 for the first and second newborns, respectively.", + "Two times nuchal cord was observed around the neck of one fetus.", + "Two umbilical cords were twisted and formed a complex of true knots and tight loops.", + "Umbilical artery blood gas showed pH 7.4, pCO2 35, HCO3 21.3, base excess -2.6 for the first fetus.", + "Umbilical artery blood gas showed pH 7.35, pCO2 32, HCO3 17.1, base excess -7 for the second fetus.", + "Both neonates were admitted to the NICU.", + "The second twin had respiratory distress syndrome.", + "All cultures and gram stains were negative.", + "Brain sonography revealed grade-I IVH in the second twin.", + "The first baby was discharged from NICU 20 days after birth.", + "The second baby was discharged from NICU 24 days after birth.", + "No complications were observed in afterbirth follow-ups.", + "The placenta and umbilical cord were sent for histological examination.", + "Anatomical pathology findings confirmed MCDA as the type of chorionicity.", + "No specific pathological changes were noted except cholangitis of the placenta." + ], + "summary": "A 31-year-old G2Ab1 with monochorionic-diamniotic twin pregnancy in the gestational age of 30 weeks presented with ruptured membrane since 3weeks before delivery. At the delivery time, multiple umbilical cord knots was found.", + "summary_subclaims": [ + "The patient is a 31-year-old G2Ab1.", + "The patient has a monochorionic-diamniotic twin pregnancy.", + "The gestational age at presentation was 30 weeks.", + "The patient had ruptured membranes since 3 weeks before delivery.", + "Multiple umbilical cord knots were found at delivery." + ] + }, + { + "id": "multiclinsum_test_596_en.txt", + "fulltext": "A 29 year old Latina female with a history of papillary thyroid carcinoma was initially treated with a total thyroidectomy, central and bilateral neck lymph node removal and subsequently with radioiodine therapy. Following this, evaluation indicated locoregional progressive disease and micrometastatic involvement in both lungs. Therapy was then initiated with 200 mg of oral sorafenib every 12 hours. However, after 4 days the patient presented with cutaneous lesions in the sole of the foot and in the first finger of the left hand which was associated with a burning pain in soles and palms and an intolerance to contact with hot surfaces. She also had significant ambulatory limitations and patchy lesions were evident in several areas of the foot and yellow blisters on the lateral aspect of the foot, metatarsal region and on the proximal phalanx of the first finger of the left hand . Given these clinical findings the dermatological reaction was classified as Grade 3 and the Sorafenib treatment was discontinued. We then initiated treatment with a topical steroid, oral antihistamines and local management with ice packs around the lesions and observed the beginning of recovery seven days after the patient discontinued the drug therapy .", + "fulltext_subclaims": [ + "The patient is a 29 year old Latina female.", + "The patient has a history of papillary thyroid carcinoma.", + "The patient was initially treated with a total thyroidectomy.", + "The patient had central and bilateral neck lymph node removal.", + "The patient subsequently had radioiodine therapy.", + "Evaluation indicated locoregional progressive disease.", + "Micrometastatic involvement was found in both lungs.", + "Therapy was initiated with 200 mg of oral sorafenib every 12 hours.", + "After 4 days, the patient presented with cutaneous lesions in the sole of the foot.", + "The patient had cutaneous lesions in the first finger of the left hand.", + "The patient had burning pain in soles and palms.", + "The patient had intolerance to contact with hot surfaces.", + "The patient had significant ambulatory limitations.", + "Patchy lesions were evident in several areas of the foot.", + "Yellow blisters were present on the lateral aspect of the foot.", + "Yellow blisters were present on the metatarsal region.", + "Yellow blisters were present on the proximal phalanx of the first finger of the left hand.", + "The dermatological reaction was classified as Grade 3.", + "Sorafenib treatment was discontinued.", + "Treatment with a topical steroid was initiated.", + "Oral antihistamines were initiated.", + "Local management with ice packs around the lesions was initiated.", + "Recovery began seven days after the patient discontinued the drug therapy." + ], + "summary": "We report a case of a 29 year old Latin woman diagnosed with papillary thyroid carcinoma, who was initially given a total thyroidectomy, central and bilateral neck lymph node removal followed by a radioiodine therapy. Subsequent evaluation indicated locoregional progressive disease and metastatic involvement in both lungs. Following this, the patient was prescribed 200 mg of sorafenib administered every 12 hours, but after four days, she presented with a skin reaction compatible with hand-foot syndrome. After discontinuation of the therapy, this reaction ceased.", + "summary_subclaims": [ + "The patient is a 29 year old Latin woman.", + "The patient was diagnosed with papillary thyroid carcinoma.", + "The patient was given a total thyroidectomy.", + "The patient had central and bilateral neck lymph node removal.", + "The patient received radioiodine therapy.", + "Subsequent evaluation indicated locoregional progressive disease.", + "Subsequent evaluation indicated metastatic involvement in both lungs.", + "The patient was prescribed 200 mg of sorafenib.", + "The sorafenib was administered every 12 hours.", + "After four days, the patient presented with a skin reaction compatible with hand-foot syndrome.", + "After discontinuation of the therapy, the reaction ceased." + ] + }, + { + "id": "multiclinsum_test_794_en.txt", + "fulltext": "A 55-year-old man, who received LT two years ago, developed diarrhea after an unclean diet 20 days ago and had difficulty breathing for five days. The patient's history included LT for cirrhosis two years ago and postoperative use of tacrolimus (2 tablets bid), Mycophenolate Mofetil (3 tablets bid), and sirolimus (1 tablet qd) to control immune-rejection with good results. The patient had recurrent diarrhea 20 days ago after an unclean diet, with symptoms of loose yellow stools with mucus 6–8 times a day, and did not improve after taking \"berberine hydrochloride\". Ten days ago, the patient's symptoms worsened, and he relieved dark green stools more than ten times a day, and gradually developed symptoms such as thirst, profoundly sunken eye sockets, palpitations and dyspnea. The patient's examination at the local hospital showed a white blood cell (WBC) count of 15. 61 × 109/L, a significant decrease in potassium ions (2. 45 mmol/L), and a significant increase in creatinine level (337 umol/L). As a result, the local hospital discontinued the patient's immunosuppressive drugs and treated diarrhea and intestinal infections with Meropenem and Montmorillonite, but the results were poor. Because the patient developed symptoms such as dyspnea and oliguria, he was diagnosed with septic shock. However, after treatment with a ventilator and Continuous Renal Replacement Therapy (CRRT), diarrhea and infection were not effectively controlled, and the symptoms worsened. As a result, the patient was transferred to the Department of Intensive Care Unit of West China Hospital.\nThe patient was admitted with ventilator-assisted ventilation. A femoral vein placement tube for CRRT used outside the hospital was found at the root of the thigh. Patient's general condition on admission : temperature 38. 4 °C; pulse 130 beats/min; respiratory rate: 18 breaths/min; blood pressure 100/67 mmHg (on norepinephrine 0. 4ug/kg/min). The patient had a small number of wet rales on lung auscultation, an oxygenation index (PO2/FIO2) of approximately 110, and no significant abnormalities on abdominal examination. The patient's laboratory findings showed a significant systemic inflammatory response, renal impairment and immunosuppressive state. Inflammatory indexes: white blood cell count 19. 21 × 109/L; neutrophil ratio 92. 7%; CRP: 190 mg/L; interleukin 6: 336 pg/L, PCT: 3. 32 ng/L; abnormal biochemical indexes: creatinine 170umol/L; potassium: 5. 23 mmol/L; immune function: lymphocyte count: 0. 45 × 109/L. The patient's abdominal CT suggested a high amount of colorectal gas stool and a dilated bowel.\nBased on the patient's admission examination and the external medical records, we initially determined that the patient was in septic shock caused by infectious diarrhea with abdominal and pulmonary infections and multiorgan functional impairment. The patient was then admitted to our hospital and immediately given imipenem cystatin 1 g q8h and voriconazole 0. 2 g q12h for anti-infection. The patient's immunosuppressive drugs continued to be stopped. The patient's routine stool test was sent to identify the pathogen causing the diarrhea, but no meaningful results were obtained. On the second day, the patient's blood culture suggested Gram-positive coccus infection and chest CT suggested fungal infection. We added amphotericin B 10 mg bid and tigecycline 100 mg q12h to strengthen the anti-infection. By day 5, the patient's temperature peak was gradually reduced, and the oxygenation index rose to approximately 300. We reduced the dose of paroxysmal sedative medication discontinue the ventilator and transfer it out of the intensive care unit. As the patient's lymphocyte count rose to 1. 58 × 109/L, we reintroduced him to Mycophenolate Mofetil 500 mg bid to suppress the patient's immune function.\nOn day 7, the patient again developed massive watery diarrhea and unstable blood pressure, a decrease in oxygenation index(PO2/FIO2) to 200, increased inflammatory markers, and abnormal liver function. We considered a drug-related liver injury and parasite-associated diarrhea. So we stopped the patient's enteral nutrition, added antidiarrhea (minocycline hydrochloride) and hepatoprotective drugs (polyene phosphatidylcholine) and adjusted the antibiotic regimen to ceftazidime avibactam (2. 5 g q12h), amantadine (1000 mg q8h), voriconazole (0. 1 g q12h) and mucilage sulfate (750, 000u q12h). To clarify the aetiology of the patient's diarrhea, we performed a gastroscopy on day 8. The stereoscopic presentation was : segmental mucosal changes in the cecum department and ascending colon, suspicious of specific infections. Because the patient's multiple stool tests were negative, we considered atypical pathogenic infections. Therefore, we stained the patient's stool specimen with antacid and performed high-throughput sequencing (NGS) on the blood specimen. After two days, a large number of Cryptosporidium was detected in the patient's stool . NGS detection of Cryptosporidium parvum sequence number 33 with the specific information that NGS detection covers a total length of 2951 (bp) on the genome with coverage of 0. 0332% and an average depth of 1. 00X, suggesting the presence of large amounts of Cryptosporidium in the blood of this patients . Furthermore, we immediately discontinued Mycophenolate Mofetil and looked for an anti-Cryptosporidium infection treatment option. According to previous reports, Cryptosporidium infection is frequently seen in children with primary immunodeficiency. Cryptosporidium infection causes symptoms such as sclerosing cholangitis and pulmonary Cryptosporidium infection in children with immunodeficiency. There was a high degree of similarity to the present case regarding both symptoms and findings. In a case report of a CD40L-deficient infant diagnosed with Cryptosporidium infection, after treatment with nitazoxanide and azithromycine, the patient was doing well, this report served as an important reminder for our treatment, and we immediately reviewed the instructions for NTZ [, ]. NTZ is the only approved anti-Cryptosporidium drug on the market. Because NTZ is not recommended in the instructions for use in an immunodeficient population, we used an anti-Cryptosporidium regimen of oral azithromycin (1000 mg tid) and alliin (500 mg tid). Five days after that, the patient showed a slight improvement in diarrhea, but liver and kidney function continued to deteriorate, and we administered continuous CRRT. On day 18, as the patient's glutamyl transpeptidase and alkaline phosphatase continued to rise, we considered Cryptosporidium retrograde biliary infection. To prevent the development of sclerosing cholangitis and immunorejection, we changed the anti-Cryptosporidium infection regimen to NTZ (500 mg tid) and allicin (500 mg tid) while continuously monitoring the patient's immune function and using cyclosporine to suppress immune function if necessary to keep CD4 + T cells were controlled at 100–300/mm3. The treatment plan had a good effect. The number of diarrhea gradually decreased, liver and kidney function gradually recovered, CRRT was stopped on day 22, and the patient was taken off the ventilator on day 23. On days 24 and 25, the patient underwent faecal antacid staining, and no Cryptosporidium was found. On day 28, the patient was transferred to the general ward and recovered well with his family. As the patient's renal function is severely compromised, we recommend that patients regularly review their renal function and pay attention to preventing infection from avoiding progression to the stage of renal failure.", + "fulltext_subclaims": [ + "The patient is a 55-year-old man.", + "The patient received a liver transplant two years ago.", + "The patient developed diarrhea after an unclean diet 20 days ago.", + "The patient had difficulty breathing for five days.", + "The patient's history included liver transplant for cirrhosis two years ago.", + "The patient was taking tacrolimus (2 tablets bid), Mycophenolate Mofetil (3 tablets bid), and sirolimus (1 tablet qd) to control immune-rejection.", + "The patient had recurrent diarrhea 20 days ago after an unclean diet.", + "The patient had loose yellow stools with mucus 6–8 times a day.", + "The patient did not improve after taking berberine hydrochloride.", + "Ten days ago, the patient's symptoms worsened.", + "The patient had dark green stools more than ten times a day.", + "The patient developed symptoms such as thirst, profoundly sunken eye sockets, palpitations, and dyspnea.", + "The patient's white blood cell count was 15.61 × 109/L.", + "The patient's potassium ions were 2.45 mmol/L.", + "The patient's creatinine level was 337 umol/L.", + "The local hospital discontinued the patient's immunosuppressive drugs.", + "The local hospital treated the patient with Meropenem and Montmorillonite.", + "The patient was diagnosed with septic shock.", + "The patient was treated with a ventilator and Continuous Renal Replacement Therapy (CRRT).", + "The patient was transferred to the Department of Intensive Care Unit of West China Hospital.", + "The patient was admitted with ventilator-assisted ventilation.", + "The patient had a femoral vein placement tube for CRRT.", + "The patient's temperature on admission was 38.4 °C.", + "The patient's pulse on admission was 130 beats/min.", + "The patient's blood pressure on admission was 100/67 mmHg.", + "The patient was receiving norepinephrine 0.4ug/kg/min.", + "The patient's white blood cell count on admission was 19.21 × 109/L.", + "The patient's neutrophil ratio on admission was 92.7%.", + "The patient's CRP on admission was 190 mg/L.", + "The patient's interleukin 6 on admission was 336 pg/L.", + "The patient's PCT on admission was 3.32 ng/L.", + "The patient's creatinine on admission was 170umol/L.", + "The patient's potassium on admission was 5.23 mmol/L.", + "The patient's lymphocyte count on admission was 0.45 × 109/L.", + "The patient's abdominal CT suggested a high amount of colorectal gas stool.", + "The patient's abdominal CT suggested a dilated bowel.", + "The patient was initially determined to be in septic shock caused by infectious diarrhea.", + "The patient was given imipenem cystatin 1 g q8h and voriconazole 0.2 g q12h.", + "The patient's immunosuppressive drugs continued to be stopped.", + "The patient's routine stool test did not yield meaningful results.", + "The patient's blood culture suggested Gram-positive coccus infection.", + "The patient's chest CT suggested fungal infection.", + "The patient was given amphotericin B 10 mg bid and tigecycline 100 mg q12h.", + "By day 5, the patient's temperature peak was gradually reduced.", + "By day 5, the patient's oxygenation index rose to approximately 300.", + "By day 5, the ventilator was discontinued.", + "By day 5, the patient was transferred out of the intensive care unit.", + "As the patient's lymphocyte count rose to 1.58 × 109/L, Mycophenolate Mofetil 500 mg bid was reintroduced.", + "On day 7, the patient again developed massive watery diarrhea.", + "On day 7, the patient had unstable blood pressure.", + "On day 7, the patient's oxygenation index decreased to 200.", + "On day 7, the patient had increased inflammatory markers.", + "On day 7, the patient had abnormal liver function.", + "The patient's multiple stool tests were negative.", + "The patient's gastroscopy showed segmental mucosal changes in the cecum department and ascending colon.", + "The patient's gastroscopy suggested specific infections.", + "The patient's stool specimen was stained with antacid.", + "The patient's blood specimen was subjected to high-throughput sequencing (NGS).", + "A large number of Cryptosporidium were detected in the patient's stool.", + "NGS detected Cryptosporidium parvum sequence number 33.", + "NGS detection covered a total length of 2951 (bp) on the genome.", + "NGS detection had a coverage of 0.0332%.", + "NGS detection had an average depth of 1.00X.", + "The presence of large amounts of Cryptosporidium in the blood of this patient was suggested.", + "Mycophenolate Mofetil was discontinued.", + "Cryptosporidium infection is frequently seen in children with primary immunodeficiency.", + "Cryptosporidium infection causes symptoms such as sclerosing cholangitis and pulmonary Cryptosporidium infection in children with immunodeficiency.", + "There was a high degree of similarity to the present case regarding both symptoms and findings.", + "In a case report of a CD40L-deficient infant diagnosed with Cryptosporidium infection, after treatment with nitazoxanide and azithromycine, the patient was doing well.", + "NTZ is the only approved anti-Cryptosporidium drug on the market.", + "NTZ is not recommended in the instructions for use in an immunodeficient population.", + "The patient was given an anti-Cryptosporidium regimen of oral azithromycin (1000 mg tid) and alliin (500 mg tid).", + "Five days after treatment, the patient showed a slight improvement in diarrhea.", + "Five days after treatment, the patient's liver and kidney function continued to deteriorate.", + "Continuous CRRT was administered.", + "On day 18, the patient's glutamyl transpeptidase and alkaline phosphatase continued to rise.", + "Cryptosporidium retrograde biliary infection was considered.", + "The anti-Cryptosporidium infection regimen was changed to NTZ (500 mg tid) and allicin (500 mg tid).", + "Cyclosporine was used to suppress immune function if necessary.", + "CD4 + T cells were controlled at 100–300/mm3.", + "The treatment plan had a good effect.", + "The number of diarrhea gradually decreased.", + "Liver and kidney function gradually recovered.", + "CRRT was stopped on day 22.", + "The patient was taken off the ventilator on day 23.", + "On days 24 and 25, the patient underwent faecal antacid staining.", + "No Cryptosporidium was found on days 24 and 25.", + "On day 28, the patient was transferred to the general ward.", + "The patient recovered well with his family.", + "The patient's renal function is severely compromised.", + "The patient is recommended to regularly review renal function.", + "The patient is recommended to pay attention to preventing infection.", + "The patient is recommended to avoid progression to the stage of renal failure." + ], + "summary": "A patient who had received LT for two years was admitted to the hospital with diarrhea more than 20 days after eating an unclean diet. After failing treatment at a local hospital, he was admitted to Intensive Care Unit after going into septic shock. The patient presented hypovolemia due to diarrhea, which progressed to septic shock. The patient's sepsis shock was controlled after receiving multiple antibiotic combinations and fluid resuscitation. However, the persistent diarrhea, as the culprit of the patient's electrolyte disturbance, hypovolemia, and malnutrition, was unsolved. The causative agent of diarrhea, Cryptosporidium infection, was identified by colonoscopy, faecal antacid staining, and blood high-throughput sequencing (NGS). The patient was treated by reducing immunosuppression and Nitazoxanide (NTZ), which proved effective in this case.", + "summary_subclaims": [ + "The patient had received LT for two years.", + "The patient was admitted to the hospital with diarrhea more than 20 days after eating an unclean diet.", + "The patient was admitted to Intensive Care Unit after going into septic shock.", + "The patient presented hypovolemia due to diarrhea.", + "The patient's sepsis shock was controlled after receiving multiple antibiotic combinations and fluid resuscitation.", + "The persistent diarrhea was the culprit of the patient's electrolyte disturbance, hypovolemia, and malnutrition.", + "The causative agent of diarrhea, Cryptosporidium infection, was identified by colonoscopy, faecal antacid staining, and blood high-throughput sequencing (NGS).", + "The patient was treated by reducing immunosuppression and Nitazoxanide (NTZ).", + "Nitazoxanide (NTZ) proved effective in this case." + ] + }, + { + "id": "multiclinsum_test_1872_en.txt", + "fulltext": "17 year old girl presented to Emergency department with fever, malaise for 3 months, left foot gangrene for 2 months, left sided hemiparesis for 4 days. A diagnosis of Infective Endocarditis was made on Transthoracic echo and percutaneous embolectomy was attempted at another hospital which was complicated by a left hemiplegia. On examination she was found to be tachycardiac, tachypneic, hypotensive and febrile. GCS was 4/15 and she had a left hemiplegia. Left foot showed gangrene of the medial 3 digits and peripheral pulses including the posterior tibial and dorsalis pedis of the left were weak. There was a pansystolic murmur at the apex with radiation to the axilla and another early diastolic murmur at the aortic area radiating to the carotids. CT scan brain was done that showed a right middle cerebral artery stroke. Transthoracic echo was done which revealed large vegetation on both mitral valve leaflets with a size of 32 X 15 mm on the posterior mitral leaflet ( Additional file : Pic. 1). Vegetation was also seen at the septal leaflet of tricuspid valve and aortic valve.\nHistopathology of her vegetations revealed moderate acute and chronic inflammation with fibrin and granulation tissue formation along with granulomas. The mitral valve showed focal necrosis with calcification . The granulomas were composed of typical epitheloid cells and multinucleated giant cells. Cultures of the aortic valve for Acid Fast Bacilli were negative.\nShe underwent dual valve replacement for mitral and aortic valves and the tricuspid valve was repaired surgically as it was anatomically intact ( Additional file : Pics. 2, 3). She was weak on her left side and required regular physiotherapy. Antituberculous therapy was started with anticoagulation.", + "fulltext_subclaims": [ + "The patient is a 17 year old girl.", + "She presented with fever and malaise for 3 months.", + "She had left foot gangrene for 2 months.", + "She had left sided hemiparesis for 4 days.", + "A diagnosis of Infective Endocarditis was made on Transthoracic echo.", + "Percutaneous embolectomy was attempted at another hospital.", + "The embolectomy was complicated by a left hemiplegia.", + "On examination, she was tachycardiac.", + "On examination, she was tachypneic.", + "On examination, she was hypotensive.", + "On examination, she was febrile.", + "GCS was 4/15.", + "She had a left hemiplegia.", + "Left foot showed gangrene of the medial 3 digits.", + "Peripheral pulses including the posterior tibial and dorsalis pedis of the left were weak.", + "There was a pansystolic murmur at the apex with radiation to the axilla.", + "There was an early diastolic murmur at the aortic area radiating to the carotids.", + "CT scan brain showed a right middle cerebral artery stroke.", + "Transthoracic echo revealed large vegetation on both mitral valve leaflets.", + "The vegetation on the posterior mitral leaflet was 32 X 15 mm.", + "Vegetation was also seen at the septal leaflet of tricuspid valve.", + "Vegetation was also seen at the aortic valve.", + "Histopathology of the vegetations revealed moderate acute and chronic inflammation.", + "Histopathology showed fibrin and granulation tissue formation.", + "Histopathology showed granulomas.", + "The granulomas were composed of typical epitheloid cells.", + "The granulomas were composed of multinucleated giant cells.", + "Cultures of the aortic valve for Acid Fast Bacilli were negative.", + "She underwent dual valve replacement for mitral and aortic valves.", + "The tricuspid valve was repaired surgically.", + "The tricuspid valve was anatomically intact.", + "She was weak on her left side.", + "She required regular physiotherapy.", + "Antituberculous therapy was started.", + "Anticoagulation was started." + ], + "summary": "We report the case of a 17 year old immunocompetent girl who presented with history of fever, malaise, foot gangrene and a left sided hemiparesis. On investigation she was found to have infective endocarditis involving the aortic, mitral and tricuspid valves. She had developed a right middle cerebral artery stroke. She underwent dual valve replacement and tricuspid repair. The vegetations showed granulomatous inflammation but blood cultures and other biological specimen cultures were negative for any organisms. She was started on antituberculous treatment and anticoagulation.", + "summary_subclaims": [ + "The patient is a 17 year old immunocompetent girl.", + "She presented with history of fever.", + "She presented with history of malaise.", + "She presented with foot gangrene.", + "She presented with a left sided hemiparesis.", + "She was found to have infective endocarditis involving the aortic, mitral and tricuspid valves.", + "She had developed a right middle cerebral artery stroke.", + "She underwent dual valve replacement.", + "She underwent tricuspid repair.", + "The vegetations showed granulomatous inflammation.", + "Blood cultures were negative for any organisms.", + "Other biological specimen cultures were negative for any organisms.", + "She was started on antituberculous treatment.", + "She was started on anticoagulation." + ] + }, + { + "id": "multiclinsum_test_242_en.txt", + "fulltext": "A 59-year-old right-handed Japanese woman had difficulty in writing Kanji. She could neither recognize forms of the Kanji characters clearly nor write them. One month later, she developed progressive cognitive impairment; however, her social behavior remained appropriate.\nA neurological examination performed two months after the disease onset revealed mild word-finding difficulty and constructive disturbance such as copying simple diagrams. Hyperreflexia was present in her jaw and lower limbs. Her bilateral extensor plantar reflexes were positive, however, she showed no cerebellar ataxia, anopsia, myoclonus, or extrapyramidal signs. Moreover, neither ideomotor apraxia nor ideational apraxia was apparent.\nThe Standard Language Test of Aphasia, a standardized test for Japanese aphasic patients, performed three months after the disease onset revealed impaired dictation of Kanji words; however, other categories of the test were scored well, that is, dictation of Kana letters, pronunciation of words written in Kanji and Kana, and repetition and auditory comprehension of words and sentences. She scored 24 on the Mini-Mental State Examination with impairments in delayed recall, calculation, and copying interlocking pentagons.\nA hematological examination revealed no abnormalities. An investigation of the cerebrospinal fluid (CSF) disclosed increased levels of 14-3-3 protein (616μg/mL) and total tau protein (1217pg/mL), although cell counts and protein levels were normal. Abnormal conformation of PrPres was detected in the CSF by real-time quaking-induced conversion (RT-QUIC) .\nThe electroencephalogram showed an 8 to 10 Hz basic wave pattern with no periodic discharges. Diffusion-weighted imaging (DWI) on magnetic resonance imaging (MRI) showed diffuse hyperintensity in the bilateral cerebral cortices of the parietal, occipital, and temporal lobes . Single-photon emission computed tomography (SPECT) scans, evaluated using the easy z-score imaging system, displayed hypoperfusion in the bilateral parietal and occipital lobes, the left temporal lobe, and in the left posterior inferior temporal lobe . No mutations were detected in the open reading frame of the PrP gene, and polymorphisms at codons 129 and 219 were homozygous for methionine and glutamine, respectively. Although our patient did not meet the World Health Organization (WHO) clinical diagnostic criteria for sCJD, we clinically diagnosed her with sCJD supposedly an MM2-cortical type, based on the MRI findings, elevation of 14-3-3 and tau protein levels in the CSF, and a positive result upon RT-QUIC [,].\nAlthough her cognitive decline progressed, she had lived more than two years after the disease onset.", + "fulltext_subclaims": [ + "The patient was a 59-year-old right-handed Japanese woman.", + "She had difficulty in writing Kanji.", + "She could neither recognize forms of the Kanji characters clearly nor write them.", + "One month later, she developed progressive cognitive impairment.", + "Her social behavior remained appropriate.", + "A neurological examination performed two months after the disease onset revealed mild word-finding difficulty.", + "A neurological examination performed two months after the disease onset revealed constructive disturbance such as copying simple diagrams.", + "Hyperreflexia was present in her jaw and lower limbs.", + "Her bilateral extensor plantar reflexes were positive.", + "She showed no cerebellar ataxia.", + "She showed no anopsia.", + "She showed no myoclonus.", + "She showed no extrapyramidal signs.", + "Neither ideomotor apraxia nor ideational apraxia was apparent.", + "The Standard Language Test of Aphasia, performed three months after the disease onset, revealed impaired dictation of Kanji words.", + "Other categories of the test were scored well, that is, dictation of Kana letters, pronunciation of words written in Kanji and Kana, and repetition and auditory comprehension of words and sentences.", + "She scored 24 on the Mini-Mental State Examination.", + "A hematological examination revealed no abnormalities.", + "An investigation of the cerebrospinal fluid (CSF) disclosed increased levels of 14-3-3 protein (616μg/mL).", + "An investigation of the CSF disclosed increased levels of total tau protein (1217pg/mL).", + "Abnormal conformation of PrPres was detected in the CSF by real-time quaking-induced conversion (RT-QUIC).", + "The electroencephalogram showed an 8 to 10 Hz basic wave pattern with no periodic discharges.", + "Diffusion-weighted imaging (DWI) on magnetic resonance imaging (MRI) showed diffuse hyperintensity in the bilateral cerebral cortices of the parietal, occipital, and temporal lobes.", + "Single-photon emission computed tomography (SPECT) scans displayed hypoperfusion in the bilateral parietal and occipital lobes.", + "SPECT scans displayed hypoperfusion in the left temporal lobe.", + "SPECT scans displayed hypoperfusion in the left posterior inferior temporal lobe.", + "No mutations were detected in the open reading frame of the PrP gene.", + "Polymorphisms at codons 129 and 219 were homozygous for methionine and glutamine, respectively.", + "The patient did not meet the World Health Organization (WHO) clinical diagnostic criteria for sCJD.", + "We clinically diagnosed her with sCJD supposedly an MM2-cortical type.", + "The diagnosis was based on the MRI findings.", + "The diagnosis was based on the elevation of 14-3-3 and tau protein levels in the CSF.", + "The diagnosis was based on a positive result upon RT-QUIC.", + "Although her cognitive decline progressed, she had lived more than two years after the disease onset." + ], + "summary": "A 59-year-old right-handed Japanese woman complained of agraphia of Kanji (Chinese characters) as an initial symptom. A neurological examination revealed mild word-finding difficulty, constructive disturbance, hyperreflexia in her jaw and lower limbs, and bilateral extensor plantar reflexes. An examination of her cerebrospinal fluid revealed increased levels of 14-3-3 and total tau proteins, and abnormal conformation of the proteinase K-resistant prion protein. Diffusion-weighted magnetic resonance imaging showed diffuse hyperintensity in bilateral cerebral cortices. Single-photon emission computed tomography scans revealed hypoperfusion in the left temporal lobe, bilateral parietal and occipital lobes. An analysis of the prion protein gene demonstrated no mutation with homozygous for methionine at the codon 129. We diagnosed our patient with sporadic Creutzfeldt-Jakob disease. Although a histological examination was not performed, it was assumed that our patient could be the MM2-cortical type according to the clinical findings and the elevated levels of 14-3-3 protein in her cerebrospinal fluid. The left posterior inferior temporal area, which was affected in our patient as a hypoperfusion area, is associated with selecting and recalling Kanji characters.", + "summary_subclaims": [ + "The patient is a 59-year-old right-handed Japanese woman.", + "The patient complained of agraphia of Kanji as an initial symptom.", + "A neurological examination revealed mild word-finding difficulty.", + "A neurological examination revealed constructive disturbance.", + "A neurological examination revealed hyperreflexia in her jaw and lower limbs.", + "A neurological examination revealed bilateral extensor plantar reflexes.", + "An examination of her cerebrospinal fluid revealed increased levels of 14-3-3 protein.", + "An examination of her cerebrospinal fluid revealed increased levels of total tau protein.", + "An examination of her cerebrospinal fluid revealed abnormal conformation of the proteinase K-resistant prion protein.", + "Diffusion-weighted magnetic resonance imaging showed diffuse hyperintensity in bilateral cerebral cortices.", + "Single-photon emission computed tomography scans revealed hypoperfusion in the left temporal lobe.", + "Single-photon emission computed tomography scans revealed hypoperfusion in the bilateral parietal and occipital lobes.", + "An analysis of the prion protein gene demonstrated no mutation.", + "The patient was homozygous for methionine at the codon 129.", + "The patient was diagnosed with sporadic Creutzfeldt-Jakob disease.", + "A histological examination was not performed.", + "It was assumed that the patient could be the MM2-cortical type.", + "The left posterior inferior temporal area was affected as a hypoperfusion area.", + "The left posterior inferior temporal area is associated with selecting and recalling Kanji characters." + ] + }, + { + "id": "multiclinsum_test_1961_en.txt", + "fulltext": "A 43-year-old man with HF secondary to dyspnea was admitted to our hospital. The patient's height was 160 cm, body weight was 109 kg, and body mass index was 42.5 kg/m2. Past medical history included diabetes mellitus and sleep apnea. Upon admission, the patient experienced orthopnea and whole-body edema. Laboratory data indicated a creatinine of 1.3 mg/dl, an estimated glomerular filtration rate of 49 ml/min/1.73 m2 and an N-terminal pro-brain natriuretic peptide level of 4,177 pg/ml. Electrocardiography revealed sinus tachycardia and a left ventricular ejection fraction of 20% with diffuse left ventricular hypokinesis. Plain chest radiography revealed a cardiothoracic ratio of 66% and a costophrenic obtuse angle. The patient was diagnosed with AHF and was treated with intravenous furosemide and oxygen inhalation. However, the patient developed respiratory failure and low-output syndrome on the 7th hospital day. The patient was transferred to the cardiac care unit (CCU), and treatment with noradrenaline, dobutamine, and noninvasive positive pressure ventilation was initiated. On the 19th hospital day, right heart catheterization indicated Forrester subset IV (pulmonary artery wedge pressure, 27 mmHg; cardiac index: 1.6 L/min/m2), and coronary angiography revealed no significant stenosis. Based on the clinical course and endomyocardial biopsy of the right ventricular septum, the patient was diagnosed with idiopathic dilated cardiomyopathy on the 23rd hospital day. Because the patient was young and had developed catecholamine-dependent HF, heart transplantation was considered. However, severe obesity was an obstacle to registration. We started B-SES (G-TES; Homer Ion Laboratory, Tokyo, Japan) in parallel with normal cardiac rehabilitation and performed gradual withdrawal of catecholamines and titration of bisoprolol. On the 48th day of hospitalization, the patient was withdrawn from noradrenaline. The patient was transferred from the CCU to the general ward on the 92nd day. The patient's symptoms improved to NYHA II with titration of bisoprolol, ivabradine, valsartan, spironolactone, dapagliflozin and furosemide, along with cardiac rehabilitation. In addition, we provided life modification program to the patient because eating habits and sedentary life style had contributed to his obesity. The patient was discharged with a body weight of 75.6 kg on the 113th hospital day. This case report has anonymized patient information, and photographs including parts of the body (including the face) have been processed to ensure that the individual cannot be identified. We obtained written informed consent from the patient for publication.", + "fulltext_subclaims": [ + "The patient was a 43-year-old man.", + "The patient had HF secondary to dyspnea.", + "The patient's body mass index was 42.5 kg/m2.", + "The patient's past medical history included diabetes mellitus.", + "The patient's past medical history included sleep apnea.", + "Upon admission, the patient experienced orthopnea.", + "Upon admission, the patient had whole-body edema.", + "The patient's creatinine was 1.3 mg/dl.", + "The patient's estimated glomerular filtration rate was 49 ml/min/1.73 m2.", + "The patient's N-terminal pro-brain natriuretic peptide level was 4,177 pg/ml.", + "Electrocardiography revealed a left ventricular ejection fraction of 20%.", + "The patient was diagnosed with AHF.", + "The patient was treated with intravenous furosemide.", + "The patient was treated with oxygen inhalation.", + "The patient developed respiratory failure on the 7th hospital day.", + "The patient developed low-output syndrome on the 7th hospital day.", + "The patient was transferred to the cardiac care unit.", + "Right heart catheterization indicated Forrester subset IV.", + "The patient's pulmonary artery wedge pressure was 27 mmHg.", + "The patient's cardiac index was 1.6 L/min/m2.", + "Coronary angiography revealed no significant stenosis.", + "The patient was diagnosed with idiopathic dilated cardiomyopathy.", + "Heart transplantation was considered.", + "Severe obesity was an obstacle to registration.", + "B-SES (G-TES) was started.", + "The patient was withdrawn from noradrenaline on the 48th day of hospitalization.", + "The patient was transferred from the CCU to the general ward on the 92nd day.", + "The patient's symptoms improved to NYHA II.", + "The patient was discharged with a body weight of 75.6 kg.", + "This case report has anonymized patient information.", + "Photographs including parts of the body have been processed to ensure that the individual cannot be identified.", + "We obtained written informed consent from the patient for publication." + ], + "summary": "A 43-year-old man with a body mass index of 41 kg/m2 was admitted to our hospital for acute heart failure due to dilated cardiomyopathy. The patient required prolonged catecholamine support owing to poor cardiac function, and heart transplantation was considered. We initiated a mobilization program, but the patient's mobility was highly limited due to severe obesity and symptomatic orthostatic hypotension. B-SES was introduced to accomplish weight loss and early ambulation. We applied an intensive monitoring program for safe use and modulated the intensity of B-SES according to physical function. During the B-SES program, the patient's body weight decreased from 89.6 kg to 78.6 kg. Sequential evaluations of body composition and skeletal muscle ultrasonography revealed improved muscle mass, quality, and physical function. Furthermore, we explored the workload of B-SES using expiratory gas analysis. No adverse events were observed during B-SES.", + "summary_subclaims": [ + "The patient was a 43-year-old man.", + "The patient had a body mass index of 41 kg/m2.", + "The patient was admitted for acute heart failure due to dilated cardiomyopathy.", + "The patient required prolonged catecholamine support.", + "Heart transplantation was considered.", + "A mobilization program was initiated.", + "The patient's mobility was highly limited due to severe obesity and symptomatic orthostatic hypotension.", + "B-SES was introduced to accomplish weight loss and early ambulation.", + "An intensive monitoring program was applied for safe use of B-SES.", + "The intensity of B-SES was modulated according to physical function.", + "During the B-SES program, the patient's body weight decreased from 89.6 kg to 78.6 kg.", + "Sequential evaluations of body composition and skeletal muscle ultrasonography revealed improved muscle mass, quality, and physical function.", + "The workload of B-SES was explored using expiratory gas analysis.", + "No adverse events were observed during B-SES." + ] + }, + { + "id": "multiclinsum_test_2129_en.txt", + "fulltext": "A 510 g Caucasian female infant without prenatally diagnosed anomalies was delivered to a previously healthy 37-year-old mother (gravida 7, para 4, ab 2) at 25.7 weeks gestation via cesarean section after pathological findings on cardiotocography and growth retardation. Apgar scores were 3, 6, and 7. The patient was intubated immediately after birth, and broad-spectrum antibiotics (ampicillin + cefotaxime) were started. EA/TEF (Gross type C) was diagnosed via chest x-ray after a nasogastric tube was unable to pass the esophagus. A Replogle tube was placed in the upper pouch with continuous suction, and an umbilical vein catheter was established. Cardiac and renal ultrasound were normal; no additional malformations were diagnosed. The three older siblings of the patient do not have any congenital anomalies and are all healthy.\nOn the first day of life (DOL) (10 hours after birth) open TEF clipping was performed via an extrapleural approach in the incubator at the neonatal intensive care unit using a titanium clip (operation time 36 minutes). To reduce the operative trauma in the initial neonatal period and enable extubation after 6 days, we decided to postpone the placement of a gastrostomy. Therefore, we applied total parenteral nutrition (TPN), which resulted in a constant elevation of direct bilirubin (maximum of 200 mg/dl). At 22 DOL (weight 725 g), we created an open gastrostomy (operation time 58 minutes). After steady weight gain (2510 g), we performed a thoracoscopic primary esophageal anastomosis (operation time 93 minutes) at 3 months of age, without tension and without any perioperative adverse events . The patient was weaned from mechanical ventilation after 4 days. A transanastomotic tube was left in place until an upper contrast swallow study was performed 7 days after surgery. After 14 days, the patient was completely on oral feeds.\nUpper endoscopy including balloon dilatations started routinely after 1.5 months postsurgery. There was no event of complete stricture. However, we performed eight dilatations during the first year of life until the anastomotic stenosis resolved. Although the patient experienced one to three respiratory infections per year, there were no events of aspiration pneumonia or sepsis. Currently, the patient swallows effortlessly at the age of 4 years and thrives well [15 kg (Percentile 28); 100 cm (Percentile 24)].", + "fulltext_subclaims": [ + "The patient was a 510 g Caucasian female infant.", + "The mother was 37 years old.", + "The mother was gravida 7, para 4, ab 2.", + "The infant was delivered at 25.7 weeks gestation.", + "The delivery was via cesarean section.", + "Apgar scores were 3, 6, and 7.", + "The patient was intubated immediately after birth.", + "Broad-spectrum antibiotics (ampicillin + cefotaxime) were started.", + "EA/TEF (Gross type C) was diagnosed via chest x-ray.", + "A Replogle tube was placed in the upper pouch with continuous suction.", + "An umbilical vein catheter was established.", + "Cardiac and renal ultrasound were normal.", + "No additional malformations were diagnosed.", + "The three older siblings of the patient do not have any congenital anomalies.", + "The three older siblings are all healthy.", + "On the first day of life, open TEF clipping was performed via an extrapleural approach.", + "The TEF clipping was performed in the incubator at the neonatal intensive care unit.", + "A titanium clip was used for the TEF clipping.", + "The operation time for the TEF clipping was 36 minutes.", + "A gastrostomy was postponed to reduce operative trauma.", + "Total parenteral nutrition (TPN) was applied.", + "TPN resulted in a constant elevation of direct bilirubin.", + "The maximum direct bilirubin level was 200 mg/dl.", + "An open gastrostomy was created at 22 days of life.", + "The operation time for the gastrostomy was 58 minutes.", + "A thoracoscopic primary esophageal anastomosis was performed at 3 months of age.", + "The operation time for the anastomosis was 93 minutes.", + "The anastomosis was performed without tension.", + "There were no perioperative adverse events.", + "The patient was weaned from mechanical ventilation after 4 days.", + "A transanastomotic tube was left in place until an upper contrast swallow study was performed.", + "The upper contrast swallow study was performed 7 days after surgery.", + "The patient was completely on oral feeds after 14 days.", + "Upper endoscopy including balloon dilatations started routinely after 1.5 months postsurgery.", + "There was no event of complete stricture.", + "Eight dilatations were performed during the first year of life.", + "The anastomotic stenosis resolved.", + "The patient experienced one to three respiratory infections per year.", + "There were no events of aspiration pneumonia.", + "There were no events of sepsis.", + "The patient swallows effortlessly at the age of 4 years.", + "The patient's weight at 4 years was 15 kg (Percentile 28).", + "The patient's height at 4 years was 100 cm (Percentile 24)." + ], + "summary": "After resuscitation and intubation, the tracheoesophageal fistula was closed on the first day of life in the neonatal intensive care unit via an extrapleural approach using a titanium clip. On the sixth day of life, the Caucasian child was extubated. To minimize the operative trauma in the initial neonatal period, we prolonged gastrostomy placement until the 22nd day of life (weight 725 g). At the age of 3 months (weight 2510 g), thoracoscopic esophageal anastomosis was performed. The postoperative course was unremarkable. During the further clinical course, eight esophageal dilations were necessary. Currently, the patient swallows without difficulties at the age of 4 years and thrives well", + "summary_subclaims": [ + "The tracheoesophageal fistula was closed on the first day of life via an extrapleural approach using a titanium clip.", + "The child was extubated on the sixth day of life.", + "Gastrostomy placement was prolonged until the 22nd day of life.", + "Thoracoscopic esophageal anastomosis was performed at the age of 3 months.", + "The postoperative course was unremarkable.", + "Eight esophageal dilations were necessary during the further clinical course.", + "The patient swallows without difficulties at the age of 4 years." + ] + }, + { + "id": "multiclinsum_test_889_en.txt", + "fulltext": "A 61-year-old male with a medical history of diabetes mellitus Type II, diabetic neuropathy, and hypertension presented to the emergency department with bilateral lower extremity and right upper extremity pain after a mechanical fall resulting in the right lower extremity deformity and inability to ambulate. He reported 2 years of progressive pain and weakness in the bilateral thighs necessitating walker use, and 1 year of intermittent night sweats and bilateral shoulder pain (right greater than left). He denied weight loss, change in appetite, bisphosphonate use, osteoporosis, or previous cancers.\nRadiographs demonstrated a displaced transverse right subtrochanteric femur fracture at a stress fracture-like lesion, left incomplete transverse subtrochanteric fracture, and a large lytic lesion involving the right humeral shaft .\nThe patient’s history and multi-focal pathology were concerning for underlying malignancy. The course proceeded with biopsy and operative stabilization of his right femur. Definitive fixation of the left femur and right humerus was delayed until biopsy results and oncologic evaluation were obtained.\nA lateral approach to the right femur was utilized and a superficial vastus lateralis muscle specimen and a bone specimen from the fracture site and surrounding soft tissues were collected and sent for frozen section. These were reported as benign hematoma and cancellous bone, so additional biopsy of the intramedullary canal was performed with the Reamer/Irrigator/Aspirator [RIA]© (Depuy Synthes, West Chester, PA) before nailing and fixation with a long trochanteric-entry cephalomedullary nail.\nAfter initial procedure, the orthopedic oncology and hematology/oncology teams were consulted. Final pathology demonstrated simple marrow elements without evidence of malignancy. Given the lytic lesion in the right humerus, work-up included prostate specific antigen, serum/urine protein electrophoresis, parathyroid hormone-related protein, quantitative immunoglobulins, kappa/lambda light chains, carcinoembryonic antigen, and carbohydrate antigen 19–9. All markers were negative, but metabolic panel was notable for slightly low serum calcium at 7.7 mg/dL, elevated intact PTH at 114.2 PG/ML, and low phosphorus level at 1.1 mg/dl, suggesting paraneoplastic syndrome versus metabolic tumor (i.e., brown tumor of the parathyroid).\nThe otolaryngology service was consulted and CT imaging demonstrated multiple rib and transverse process fractures but no primary tumor or lymphadenopathy. Positron emission tomography (PET) scan showed mild diffuse nonspecific metabolic activity. CT-guided biopsy of the 3.8 × 1.5 × 0.9 cm right humerus periosteal lesion revealed bland spindle cell proliferation suggesting mixed connective tissue PMT (Image 4). FGF-23 was not available at the institution, but somatostatin receptor 2A showed variable positivity supporting the diagnosis of PMT.\nFollowing biopsy, the team proceeded with definitive management of the left subtrochanteric femur fracture and open biopsy and curettage of the right humeral lesion on hospital day 14. The patient underwent placement of a long trochanteric-entry cephalomedullary nail for the incomplete left subtrochanteric femur fracture with opening reamer biopsy.\nThe humerus lesion was then localized under fluoroscopic guidance and an anterolateral approach was used. Following dissection to the brachialis, the muscle was incised at the defect and multiple specimens were obtained. Frozen section pathology revealed spindle cell process with few atypical cells , but definitive diagnosis could not be made. During attempted curettage, the lesion was noted to be in contact with the radial nerve. Careful dissection from the nerve was performed and curettage and saucerization of the bone defect followed. The specimen was sent to pathology for definitive diagnosis and prophylactic nailing was deferred.\nFinal diagnosis of benign mixed connective tissue PMT was made on hospital day 15 and prophylactic intramedullary nailing of the right humerus was performed on hospital day 16.\nEndocrinology was consulted following definitive surgical intervention. Phosphorous and Vitamin D supplementation were initiated, and an octreotide scan was performed to rule out additional foci of PMT. Quarterly endocrinology follow-up was scheduled.\nMedical and radiation oncology were consulted during hospitalization; however, no additional treatment was recommended before discharge to skilled nursing facility on hospital day 19.\nAt the 3-, 6-, and 8-week post-operative appointments, the patient returned to the orthopedic trauma and oncology clinics noting improvement in pain and mobility. Radiographs were performed at orthopedic follow-up at 2–3-month intervals .\nEndocrinology continued to manage his persistent osteomalacia. Despite medical management, he developed delayed union of the bilateral femur fractures and multiple nonoperatively treated osteomalacia-induced fractures (fifth metatarsal fracture and bilateral ilium fractures).\nDue to insurance, the patient was unable to continue endocrinologic follow-up at 15 months postoperatively and discontinued vitamin supplementation. Eighteen months following initial presentation, he returned to orthopedic oncology with increased pain and swelling in the right thigh and humerus concerning for tumor recurrence. PET scan revealed increased metabolic activity in the right humerus. Given previous excision, the patient underwent radiation (4500 cGy) to the right humeral lesion with resolution of pain without further lucency or fracture.\nDespite radiotherapy and vitamin supplementation, the patient continued to report right thigh pain 2-year post-surgery. Laboratory evaluation revealed PTH of 118.4 pg/mL and calcium of 8.1 mg/dL. His failure to return to normal PTH (despite imaging indicating resolution of the PMT) was concerning for alternative cause of hyperparathyroidism. Further work-up and bone stimulator were initiated. Endocrinologic and otolaryngologic evaluations for primary hyperparathyroidism were negative. Vitamin D, phosphate, and alendronate therapies were initiated to improve bone density. Within 5 months, his PTH decreased to 97.5 pg/mL, calcium increased to 9.7 mg/dL, and his femur fracture had healed with complete resolution of pain.\nThe patient continues to follow-up with the orthopedic oncology and orthopedic trauma service now 6-year post-surgical intervention without recurrence .", + "fulltext_subclaims": [ + "The patient is a 61-year-old male.", + "He has a medical history of diabetes mellitus Type II.", + "He has a medical history of diabetic neuropathy.", + "He has a medical history of hypertension.", + "He presented with bilateral lower extremity and right upper extremity pain.", + "He had a mechanical fall resulting in right lower extremity deformity.", + "He was unable to ambulate.", + "He reported 2 years of progressive pain and weakness in the bilateral thighs.", + "He reported 1 year of intermittent night sweats.", + "He reported bilateral shoulder pain.", + "He denied weight loss.", + "He denied change in appetite.", + "He denied bisphosphonate use.", + "He denied osteoporosis.", + "He denied previous cancers.", + "Radiographs demonstrated a displaced transverse right subtrochanteric femur fracture at a stress fracture-like lesion.", + "Radiographs demonstrated a left incomplete transverse subtrochanteric fracture.", + "Radiographs demonstrated a large lytic lesion involving the right humeral shaft.", + "The patient’s history and multi-focal pathology were concerning for underlying malignancy.", + "The course proceeded with biopsy and operative stabilization of his right femur.", + "Definitive fixation of the left femur and right humerus was delayed until biopsy results and oncologic evaluation were obtained.", + "A lateral approach to the right femur was utilized.", + "A superficial vastus lateralis muscle specimen and a bone specimen from the fracture site and surrounding soft tissues were collected and sent for frozen section.", + "These were reported as benign hematoma and cancellous bone.", + "Additional biopsy of the intramedullary canal was performed with the Reamer/Irrigator/Aspirator [RIA]©.", + "Fixation with a long trochanteric-entry cephalomedullary nail was performed.", + "After initial procedure, the orthopedic oncology and hematology/oncology teams were consulted.", + "Final pathology demonstrated simple marrow elements without evidence of malignancy.", + "Work-up included prostate specific antigen, serum/urine protein electrophoresis, parathyroid hormone-related protein, quantitative immunoglobulins, kappa/lambda light chains, carcinoembryonic antigen, and carbohydrate antigen 19–9.", + "All markers were negative.", + "The metabolic panel was notable for slightly low serum calcium at 7.7 mg/dL.", + "The metabolic panel was notable for elevated intact PTH at 114.2 PG/ML.", + "The metabolic panel was notable for low phosphorus level at 1.1 mg/dl.", + "The findings suggested paraneoplastic syndrome versus metabolic tumor.", + "CT imaging demonstrated multiple rib and transverse process fractures.", + "PET scan showed mild diffuse nonspecific metabolic activity.", + "CT-guided biopsy of the 3.8 × 1.5 × 0.9 cm right humerus periosteal lesion revealed bland spindle cell proliferation suggesting mixed connective tissue PMT.", + "Somatostatin receptor 2A showed variable positivity supporting the diagnosis of PMT.", + "The team proceeded with definitive management of the left subtrochanteric femur fracture.", + "The team proceeded with open biopsy and curettage of the right humeral lesion on hospital day 14.", + "The patient underwent placement of a long trochanteric-entry cephalomedullary nail for the incomplete left subtrochanteric femur fracture with opening reamer biopsy.", + "The humerus lesion was localized under fluoroscopic guidance.", + "An anterolateral approach was used.", + "Multiple specimens were obtained.", + "Frozen section pathology revealed spindle cell process with few atypical cells.", + "Definitive diagnosis could not be made.", + "The lesion was noted to be in contact with the radial nerve.", + "Careful dissection from the nerve was performed.", + "Curettage and saucerization of the bone defect followed.", + "Final diagnosis of benign mixed connective tissue PMT was made on hospital day 15.", + "Prophylactic intramedullary nailing of the right humerus was performed on hospital day 16.", + "Endocrinology was consulted following definitive surgical intervention.", + "Phosphorous and Vitamin D supplementation were initiated.", + "An octreotide scan was performed to rule out additional foci of PMT.", + "Quarterly endocrinology follow-up was scheduled.", + "Medical and radiation oncology were consulted during hospitalization.", + "No additional treatment was recommended before discharge.", + "The patient was discharged to a skilled nursing facility on hospital day 19.", + "At the 3-, 6-, and 8-week post-operative appointments, the patient returned to the orthopedic trauma and oncology clinics.", + "Radiographs were performed at orthopedic follow-up at 2–3-month intervals.", + "Endocrinology continued to manage his persistent osteomalacia.", + "He developed delayed union of the bilateral femur fractures.", + "He developed multiple nonoperatively treated osteomalacia-induced fractures.", + "Due to insurance, the patient was unable to continue endocrinologic follow-up at 15 months postoperatively.", + "He discontinued vitamin supplementation.", + "Eighteen months following initial presentation, he returned to orthopedic oncology with increased pain and swelling in the right thigh and humerus.", + "PET scan revealed increased metabolic activity in the right humerus.", + "Given previous excision, the patient underwent radiation (4500 cGy) to the right humeral lesion.", + "Radiation resulted in resolution of pain without further lucency or fracture.", + "Despite radiotherapy and vitamin supplementation, the patient continued to report right thigh pain 2-year post-surgery.", + "Laboratory evaluation revealed PTH of 118.4 pg/mL.", + "Laboratory evaluation revealed calcium of 8.1 mg/dL.", + "His failure to return to normal PTH was concerning for alternative cause of hyperparathyroidism.", + "Further work-up and bone stimulator were initiated.", + "Endocrinologic and otolaryngologic evaluations for primary hyperparathyroidism were negative.", + "Vitamin D, phosphate, and alendronate therapies were initiated.", + "Within 5 months, his PTH decreased to 97.5 pg/mL.", + "Within 5 months, his calcium increased to 9.7 mg/dL.", + "His femur fracture had healed with complete resolution of pain.", + "The patient continues to follow-up with the orthopedic oncology and orthopedic trauma service now 6-year post-surgical intervention.", + "There is no recurrence." + ], + "summary": "This is a case of a 61-year-old male who initially presented as a polytrauma patient, but further investigation revealed a PMT causing TIO. This report describes his initial diagnosis and management from 2015 to 2021.", + "summary_subclaims": [ + "The patient is a 61-year-old male.", + "The patient initially presented as a polytrauma patient.", + "Further investigation revealed a PMT causing TIO.", + "This report describes his initial diagnosis and management from 2015 to 2021." + ] + }, + { + "id": "multiclinsum_test_1418_en.txt", + "fulltext": "A 20-year-old woman with a history of epilepsy became aware of left hip pain radiating down to the back of her leg for 3 days. The pain progressed gradually and became so severe that she could not move. Thus, she was admitted to the local hospital and received intravenous antibiotics, cefazoline 6 g/day for her possible infection. However, her hip pain worsened, and she developed fever the following day. A pelvic computed tomography scan showed a fluid collection at the left sacroiliac joint (SIJ) and a small abscess in the left iliac muscle . The next day, her hemodynamic parameters also deteriorated despite the antibiotic treatment, and consciousness disturbance developed. She was transferred to the emergency department of our hospital.\nUpon hospital arrival, the patient’s vital signs were as follows: heart rate, 122 beats/min; blood pressure, 95/34 mmHg (norepinephrine 0.16 mcg/kg/min, dobutamine 4.0 mcg/kg/min); body temperature, 36.4 °C; and oxygen saturation while on oxygen therapy at 2 L/min via nasal cannula, 98%. Further, the following are the laboratory test results: C-reactive protein level, 16.8 mg/dL and arterial blood gas lactate level, 4.4 mmol/L .\nBased on the examination results and clinical symptoms, the patient was diagnosed with septic shock caused by SIJ infection. Ultrasonography-guided abscess aspiration was performed to drain the joint fluid and identify the bacterial species. Later, the blood and aspiration fluid culture and genetic analysis revealed the presence of S. schwarzengrund.\nBroad spectrum antibiotics (meropenem 3 g/day and vancomycin 2 g/day), vasopressors, and oxygen therapy were administered initially. The patient’s hemodynamic and respiratory status gradually improved. After obtaining the culture results, antibiotic treatment was changed to levofloxacin. Ten days after the first drainage, the fever pattern and inflammation markers such as C-reactive protein and erythrocyte sedimentation rate significantly improved.\nHowever, after the first drainage tube removal, the patient exhibited persistent fever and inflammation again, and hip magnetic resonance imaging revealed a growing abscess . Thus, we performed the second drainage from days 26 to 35. The patient was discharged on day 38 with oral ampicillin treatment for eight more weeks. Upon discharge, she had neither any symptoms nor sequelae .\nTo validate the entry route of S. schwarzengrund, we interviewed the patient in detail. Except for keeping one dog and two cats, she did not have any specific medical history, such as intravenous drug usage, recent overseas travel, diagnosis of sexually transmitted diseases, or consumption of suspicious food. She did not complain of any preceding gastrointestinal symptoms. The screening test results for immunodeficiency diseases, including HIV infection and autoimmune disorders, were negative. Genetic analysis of congenital immunodeficiency also revealed no significant findings. These results indicated that she did not have any immune system disorders.", + "fulltext_subclaims": [ + "The patient is a 20-year-old woman with a history of epilepsy.", + "She became aware of left hip pain radiating down to the back of her leg for 3 days.", + "The pain progressed gradually and became so severe that she could not move.", + "She was admitted to the local hospital and received intravenous antibiotics, cefazoline 6 g/day for her possible infection.", + "Her hip pain worsened, and she developed fever the following day.", + "A pelvic computed tomography scan showed a fluid collection at the left sacroiliac joint (SIJ) and a small abscess in the left iliac muscle.", + "Her hemodynamic parameters also deteriorated despite the antibiotic treatment.", + "Consciousness disturbance developed.", + "She was transferred to the emergency department of our hospital.", + "Upon hospital arrival, the patient’s heart rate was 122 beats/min.", + "Upon hospital arrival, the patient’s blood pressure was 95/34 mmHg.", + "Upon hospital arrival, the patient’s body temperature was 36.4 °C.", + "Upon hospital arrival, the patient’s oxygen saturation while on oxygen therapy at 2 L/min via nasal cannula was 98%.", + "The C-reactive protein level was 16.8 mg/dL.", + "The arterial blood gas lactate level was 4.4 mmol/L.", + "The patient was diagnosed with septic shock caused by SIJ infection.", + "Ultrasonography-guided abscess aspiration was performed to drain the joint fluid and identify the bacterial species.", + "The blood and aspiration fluid culture and genetic analysis revealed the presence of S. schwarzengrund.", + "Broad spectrum antibiotics (meropenem 3 g/day and vancomycin 2 g/day), vasopressors, and oxygen therapy were administered initially.", + "The patient’s hemodynamic and respiratory status gradually improved.", + "After obtaining the culture results, antibiotic treatment was changed to levofloxacin.", + "Ten days after the first drainage, the fever pattern and inflammation markers such as C-reactive protein and erythrocyte sedimentation rate significantly improved.", + "After the first drainage tube removal, the patient exhibited persistent fever and inflammation again.", + "Hip magnetic resonance imaging revealed a growing abscess.", + "We performed the second drainage from days 26 to 35.", + "The patient was discharged on day 38 with oral ampicillin treatment for eight more weeks.", + "Upon discharge, she had neither any symptoms nor sequelae.", + "To validate the entry route of S. schwarzengrund, we interviewed the patient in detail.", + "Except for keeping one dog and two cats, she did not have any specific medical history, such as intravenous drug usage, recent overseas travel, diagnosis of sexually transmitted diseases, or consumption of suspicious food.", + "She did not complain of any preceding gastrointestinal symptoms.", + "The screening test results for immunodeficiency diseases, including HIV infection and autoimmune disorders, were negative.", + "Genetic analysis of congenital immunodeficiency also revealed no significant findings.", + "These results indicated that she did not have any immune system disorders." + ], + "summary": "A 20-year-old woman presented with left hip pain, accompanied by vasopressor-requiring hypotension. Her imaging examinations showed fluid collection in her SIJ and a small abscess in the left iliac muscle. Later, the blood and aspiration fluid culture and genetic analysis revealed the presence of S. schwarzengrund. We diagnosed sacroiliac joint (SIJ) infection with septic shock caused by S. schwarzengrund. Her condition improved after performing several interventional radiology (IVR) procedures for SIJ abscesses and providing appropriate antibiotic treatment. Finally, she was discharged without any sequelae. Screening tests and genetic analysis about her immunodeficiency did not indicate a congenital disorder.", + "summary_subclaims": [ + "The patient is a 20-year-old woman.", + "She presented with left hip pain.", + "She had vasopressor-requiring hypotension.", + "Imaging showed fluid collection in her SIJ.", + "Imaging showed a small abscess in the left iliac muscle.", + "Blood and aspiration fluid culture and genetic analysis revealed S. schwarzengrund.", + "The diagnosis was sacroiliac joint infection with septic shock caused by S. schwarzengrund.", + "Her condition improved after interventional radiology procedures for SIJ abscesses.", + "She received appropriate antibiotic treatment.", + "She was discharged without any sequelae.", + "Screening tests and genetic analysis did not indicate a congenital immunodeficiency." + ] + }, + { + "id": "multiclinsum_test_1709_en.txt", + "fulltext": "A 57-year-old male presented with painful swelling in the left orbit that had occurred for 11 months. The medical history showed no chronic systemic disease, sinus infection, mucocele, previous trauma, previous eye surgery or irradiation.\nWe performed a complete ophthalmic examination. Best-corrected visual acuity was 20/25 OD and 20/70 OS. Examination of the left eye revealed a 3 mm proptosis and maximal restriction of extraocular movements in all gazes. Funduscopic examination revealed diffuse choroidal fold in the left eye . Right eye examination was unremarkable.\nComputed tomography (CT) of the orbit revealed an atypical, well-circumscribed homogeneous calcified mass attached to the posterior globe of the left orbit . Orbital magnetic resonance imaging showed a mixed heterogeneous mass with hypo and hyperintense regions . The mass was measured 1.77 × 1.41 × 2.42 cm in size in the left orbit and was located within the muscle cone.\nThe patient underwent an anterior inferior orbitotomy, and complete excision of the mass. Intraoperatively, the tumour was attached to the sclera but not attached to any of the orbital structures. The tumour wraps the inferior oblique, lateral rectus, and part of the inferior rectus muscle. The sclera was intact and the surface was slightly rough. The tumour caused indentation of the globe but did not enter the globe. Gross examination revealed an atypical, well-encapsulated grey-brown bony mass with several small, separate, nodules. The cut surface was grey-white, lobulated and bony hard in consistency. Microscopic examination revealed malignant spindle cells with abundant neoplastic bone and cartilage formation . Immunohistochemical examination was positive for vimentin and S-100 and negative for desmin, CD99 and EMA. The patient underwent PET-CT examination before surgery and found no distant metastases from this lesion or for occult primary lesions that may have led to a metastatic lesion within the orbit.\nThe 13-month follow-up included CT scans every 3 months and subsequently every 6 months. The patient encountered recurrence of the tumour. A complete ophthalmic examination was performed. Visual acuity was 20/25 OD and 20/200 OS. Examination of the left eye revealed a 1 mm proptosis and restriction of extraocular movements in all gazes. Funduscopic examination revealed diffuse choroidal fold in the left eye. Right eye examination was unremarkable. The latest orbital CT showed an irregular shape of the soft tissue in the muscle cone of the left eyeball. The lesions showed irregular massive calcification, and the tumour was close to the posterior pole, which was compressed and deformed. The boundary between the mass and the medial rectus muscle and the inferior rectus muscle was unclear, which revealed that the muscle was probably attached. The CT value of the soft tissue lesions was 52 ± 7.62 HU, while that of calcification was 319.09 ± 84.31HU. Considering the patient’s medical history, due to the invasive nature of the tumour, the patient then underwent orbital exenteration of the left orbit. The tumour was confirmed after surgery. Pathological examination showed a recurrence of extraskeletal osteosarcoma outside the orbit, and the lesion was extensively invaded by the soft tissue and the posterior sclera.\nThe pathological diagnosis was recurrent orbital extraskeletal osteosarcoma.", + "fulltext_subclaims": [ + "The patient is a 57-year-old male.", + "The patient had painful swelling in the left orbit for 11 months.", + "The medical history showed no chronic systemic disease.", + "The medical history showed no sinus infection.", + "The medical history showed no mucocele.", + "The medical history showed no previous trauma.", + "The medical history showed no previous eye surgery.", + "The medical history showed no irradiation.", + "Best-corrected visual acuity was 20/25 OD.", + "Best-corrected visual acuity was 20/70 OS.", + "Examination of the left eye revealed a 3 mm proptosis.", + "Examination of the left eye revealed maximal restriction of extraocular movements in all gazes.", + "Funduscopic examination revealed diffuse choroidal fold in the left eye.", + "CT of the orbit revealed an atypical, well-circumscribed homogeneous calcified mass attached to the posterior globe of the left orbit.", + "Orbital MRI showed a mixed heterogeneous mass with hypo and hyperintense regions.", + "The mass was measured 1.77 × 1.41 × 2.42 cm in size in the left orbit.", + "The mass was located within the muscle cone.", + "The patient underwent an anterior inferior orbitotomy.", + "The patient underwent complete excision of the mass.", + "Intraoperatively, the tumour was attached to the sclera.", + "Intraoperatively, the tumour was not attached to any of the orbital structures.", + "The tumour wraps the inferior oblique.", + "The tumour wraps the lateral rectus.", + "The tumour wraps part of the inferior rectus muscle.", + "The sclera was intact.", + "The surface of the sclera was slightly rough.", + "The tumour caused indentation of the globe.", + "The tumour did not enter the globe.", + "Gross examination revealed an atypical, well-encapsulated grey-brown bony mass with several small, separate, nodules.", + "The cut surface was grey-white, lobulated and bony hard in consistency.", + "Microscopic examination revealed malignant spindle cells with abundant neoplastic bone and cartilage formation.", + "Immunohistochemical examination was positive for vimentin.", + "Immunohistochemical examination was positive for S-100.", + "Immunohistochemical examination was negative for desmin.", + "Immunohistochemical examination was negative for CD99.", + "Immunohistochemical examination was negative for EMA.", + "The patient underwent PET-CT examination before surgery.", + "PET-CT found no distant metastases from this lesion.", + "PET-CT found no occult primary lesions that may have led to a metastatic lesion within the orbit.", + "The 13-month follow-up included CT scans every 3 months and subsequently every 6 months.", + "The patient encountered recurrence of the tumour.", + "Visual acuity was 20/25 OD.", + "Visual acuity was 20/200 OS.", + "Examination of the left eye revealed a 1 mm proptosis.", + "Examination of the left eye revealed restriction of extraocular movements in all gazes.", + "Funduscopic examination revealed diffuse choroidal fold in the left eye.", + "The latest orbital CT showed an irregular shape of the soft tissue in the muscle cone of the left eyeball.", + "The lesions showed irregular massive calcification.", + "The tumour was close to the posterior pole, which was compressed and deformed.", + "The boundary between the mass and the medial rectus muscle and the inferior rectus muscle was unclear.", + "The CT value of the soft tissue lesions was 52 ± 7.62 HU.", + "The CT value of calcification was 319.09 ± 84.31 HU.", + "The patient then underwent orbital exenteration of the left orbit.", + "The tumour was confirmed after surgery.", + "Pathological examination showed a recurrence of extraskeletal osteosarcoma outside the orbit.", + "The lesion was extensively invaded by the soft tissue.", + "The lesion was extensively invaded by the posterior sclera.", + "The pathological diagnosis was recurrent orbital extraskeletal osteosarcoma." + ], + "summary": "The present study reports a 57-year-old man with primary orbital extraskeletal osteosarcoma who presented with a history of painful swelling in the left orbit that had occurred for 11 months. Imaging of the orbit showed an atypical, well-defined heterogeneous mass attached to the posterior globe of the left orbit. The patient underwent an anterior orbitotomy and complete excision of the tumour. The mass was originated from neither the globe nor the bony orbital wall but from the soft tissue. Histopathology demonstrated an extraskeletal osteosarcoma. After 13 months of follow-up, there was apparent recurrence of the tumour. The medical history showed no complaints of previous trauma or radiotherapy.", + "summary_subclaims": [ + "The patient is a 57-year-old man.", + "The patient had primary orbital extraskeletal osteosarcoma.", + "The patient had a history of painful swelling in the left orbit.", + "The painful swelling had occurred for 11 months.", + "Imaging showed an atypical, well-defined heterogeneous mass.", + "The mass was attached to the posterior globe of the left orbit.", + "The patient underwent an anterior orbitotomy.", + "The patient had complete excision of the tumour.", + "The mass was originated from the soft tissue.", + "Histopathology demonstrated an extraskeletal osteosarcoma.", + "After 13 months of follow-up, there was apparent recurrence of the tumour.", + "The medical history showed no complaints of previous trauma.", + "The medical history showed no complaints of previous radiotherapy." + ] + }, + { + "id": "multiclinsum_test_1024_en.txt", + "fulltext": "A 51-year-old, gravida 1, para 1, Japanese female complained of abnormal genital bleeding for two months and presented to a clinic. An ovarian tumor was found during abdominal computed tomography (CT), and so the patient was referred to our hospital. The abnormal genital bleeding had stopped when she visited our hospital. An ultrasound scan of her right ovary revealed a swollen region of 7 cm in diameter, which contained multiple cysts, and the uterine endometrium was 9-mm-thick. Cervical cytology and an endometrial biopsy produced normal findings.\nOn magnetic resonance imaging (MRI), an ovarian tumor, which measured 7 cm in diameter and contained multiple cysts, was detected, and a large part of the tumor exhibited high signal intensity on T1-weighted imaging and low signal intensity on T2-weighted imaging. No solid components were detected . We decided to perform a laparoscopic right salpingo-oophorectomy. The patient’s medical history included endometriosis from the age of 25 without specific therapy and subarachnoid hemorrhaging due to the rupturing of an aneurysm at the age of 43. The patient was diagnosed with hydrocephalus after she underwent surgery for the subarachnoid hemorrhaging, and an LP shunt was inserted. Her medical history also included kidney stones, schizophrenia, hypertension, and diabetes mellitus at the age of 50. We confirmed the route of the LP shunt on a CT scan, which had been conducted at another clinic. It revealed that the LP shunt had been placed from her left flank to Douglas’ pouch . Under general anesthesia, laparoscopic right adnexectomy was performed. A 12-mm trocar was inserted at the umbilicus, and three 5-mm trocars were inserted 3 cm inside the right and left upper anterior iliac crests and on the midline of the lower abdomen. The abdominal pressure was set at 8 mmHg. The ovarian tumor was located in Douglas’ pouch and had adhered to the back of the uterus. Also, the head of the shunt tube was located in Douglas’ pouch and was an obstacle to the operation. We temporarily shifted the head of the shunt tube from Douglas’ pouch to the vesicouterine pouch to prevent damage to the shunt and ensure that the operation could be conducted smoothly . The operation time was 2 h and 11 min, and the total volume of intraoperative blood loss was 50 ml. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 3. The histological diagnosis was an endometriotic cyst. The patient was examined at 1 month after the surgery at our hospital’s outpatient clinic, and no adverse events were observed. She was followed-up at the outpatient clinic of a general practitioner.", + "fulltext_subclaims": [ + "The patient is a 51-year-old, gravida 1, para 1, Japanese female.", + "She complained of abnormal genital bleeding for two months.", + "An ovarian tumor was found during abdominal computed tomography (CT).", + "The patient was referred to our hospital.", + "The abnormal genital bleeding had stopped when she visited our hospital.", + "An ultrasound scan of her right ovary revealed a swollen region of 7 cm in diameter.", + "The swollen region contained multiple cysts.", + "The uterine endometrium was 9-mm-thick.", + "Cervical cytology produced normal findings.", + "An endometrial biopsy produced normal findings.", + "On magnetic resonance imaging (MRI), an ovarian tumor, which measured 7 cm in diameter and contained multiple cysts, was detected.", + "A large part of the tumor exhibited high signal intensity on T1-weighted imaging.", + "A large part of the tumor exhibited low signal intensity on T2-weighted imaging.", + "No solid components were detected.", + "We decided to perform a laparoscopic right salpingo-oophorectomy.", + "The patient’s medical history included endometriosis from the age of 25 without specific therapy.", + "The patient had subarachnoid hemorrhaging due to the rupturing of an aneurysm at the age of 43.", + "The patient was diagnosed with hydrocephalus after she underwent surgery for the subarachnoid hemorrhaging.", + "An LP shunt was inserted.", + "Her medical history also included kidney stones.", + "Her medical history also included schizophrenia.", + "Her medical history also included hypertension.", + "Her medical history also included diabetes mellitus at the age of 50.", + "We confirmed the route of the LP shunt on a CT scan, which had been conducted at another clinic.", + "The CT scan revealed that the LP shunt had been placed from her left flank to Douglas’ pouch.", + "Under general anesthesia, laparoscopic right adnexectomy was performed.", + "A 12-mm trocar was inserted at the umbilicus.", + "Three 5-mm trocars were inserted 3 cm inside the right and left upper anterior iliac crests and on the midline of the lower abdomen.", + "The abdominal pressure was set at 8 mmHg.", + "The ovarian tumor was located in Douglas’ pouch.", + "The ovarian tumor had adhered to the back of the uterus.", + "The head of the shunt tube was located in Douglas’ pouch and was an obstacle to the operation.", + "We temporarily shifted the head of the shunt tube from Douglas’ pouch to the vesicouterine pouch.", + "The operation time was 2 h and 11 min.", + "The total volume of intraoperative blood loss was 50 ml.", + "The patient’s postoperative course was uneventful.", + "She was discharged on postoperative day 3.", + "The histological diagnosis was an endometriotic cyst.", + "The patient was examined at 1 month after the surgery at our hospital’s outpatient clinic.", + "No adverse events were observed.", + "She was followed-up at the outpatient clinic of a general practitioner." + ], + "summary": "A 51-year-old female, in whom an LP shunt had been inserted to treat hydrocephalus after a subarachnoid hemorrhage, underwent laparoscopic right salpingo-oophorectomy for a right endometriotic cyst. We consulted a neurosurgeon and confirmed the route of the shunt. We started a normal laparoscopic procedure. The head of the shunt tube was located in Douglas' pouch and was an obstacle to the procedure. We moved the head of the shunt tube to the vesicouterine pouch and successfully conducted the standard operation. We report the case together with a literature review.", + "summary_subclaims": [ + "The patient was a 51-year-old female.", + "An LP shunt had been inserted to treat hydrocephalus.", + "The hydrocephalus was due to a subarachnoid hemorrhage.", + "The patient underwent laparoscopic right salpingo-oophorectomy.", + "The procedure was for a right endometriotic cyst.", + "A neurosurgeon was consulted.", + "The route of the shunt was confirmed.", + "The head of the shunt tube was located in Douglas' pouch.", + "The head of the shunt tube was an obstacle to the procedure.", + "The head of the shunt tube was moved to the vesicouterine pouch.", + "The standard operation was successfully conducted.", + "The case was reported together with a literature review." + ] + }, + { + "id": "multiclinsum_test_780_en.txt", + "fulltext": "A 34-year-old Taiwanese man with beta-thalassemia major had been administered routine blood transfusion and subcutaneous deferoxamine at 30 mg/kg/day for 20 years since youth. He was hospitalized for a compression fracture and myelopathy of the thoracic spine. He presented with acute onset of decreased vision, impaired color vision, and night blindness following continuous intravenous deferoxamine (98 mg/kg) for 42 days for the treatment of elevated serum ferritin level. On ophthalmic examinations, the best-corrected vision was 20/200 in the right eye and 20/40 in the left eye. The intraocular pressure measurement and anterior segment examination yielded normal results for both eyes. The fundus examination revealed multiple discrete hypo-pigmented circular lesions over the posterior pole and mid-peripheral retina in both eyes.Deferoxamine retinopathy was suspected, and the patient was switched to oral deferasirox/deferiprone. Six weeks later, there was an improvement in the best-corrected vision (20/60 in the right eye and 20/25 in the left eye) and color vision. Retinal pigmentary changes became confluent . NIR showed hyper-reflective deposits particularly in the parafoveal and perifoveal areas . SD-OCT showed multiple confluent hyper-reflective deposits in the choroid, retinal pigment epithelium (RPE) and IS/OS junction. Thickened RPE, Bruch’s membrane, and choroid space were also discovered. The IS/OS junction was most severely disrupted at the perifoveal and parafoveal areas than at the foveola area .", + "fulltext_subclaims": [ + "The patient is a 34-year-old Taiwanese man with beta-thalassemia major.", + "He had been administered routine blood transfusion and subcutaneous deferoxamine at 30 mg/kg/day for 20 years.", + "He was hospitalized for a compression fracture and myelopathy of the thoracic spine.", + "He presented with acute onset of decreased vision, impaired color vision, and night blindness.", + "He had received continuous intravenous deferoxamine (98 mg/kg) for 42 days.", + "The best-corrected vision was 20/200 in the right eye and 20/40 in the left eye.", + "The intraocular pressure measurement and anterior segment examination yielded normal results for both eyes.", + "The fundus examination revealed multiple discrete hypo-pigmented circular lesions over the posterior pole and mid-peripheral retina in both eyes.", + "Deferoxamine retinopathy was suspected.", + "The patient was switched to oral deferasirox/deferiprone.", + "Six weeks later, there was an improvement in the best-corrected vision (20/60 in the right eye and 20/25 in the left eye).", + "Retinal pigmentary changes became confluent.", + "NIR showed hyper-reflective deposits particularly in the parafoveal and perifoveal areas.", + "SD-OCT showed multiple confluent hyper-reflective deposits in the choroid, retinal pigment epithelium (RPE) and IS/OS junction.", + "Thickened RPE, Bruch’s membrane, and choroid space were also discovered.", + "The IS/OS junction was most severely disrupted at the perifoveal and parafoveal areas than at the foveola area." + ], + "summary": "A 34-year-old man with thalassemia major complained of nyctalopia and decreased vision following high-dose intravenous deferoxamine to treat systemic iron overload. Fundus examination revealed multiple discrete hypo-pigmented lesions at the posterior pole and mid-peripheral retina. Recovery was partial following cessation of desferrioxamine six weeks later. A follow-up SD-OCT showed multiple accumulated hyper-reflective deposits primarily in the choroid, retina pigment epithelium (RPE), and inner segment and outer segment (IS/OS) junction.", + "summary_subclaims": [ + "The patient is a 34-year-old man with thalassemia major.", + "The patient complained of nyctalopia.", + "The patient reported decreased vision.", + "The patient received high-dose intravenous deferoxamine.", + "The deferoxamine was administered to treat systemic iron overload.", + "Fundus examination revealed multiple discrete hypo-pigmented lesions.", + "The lesions were located at the posterior pole and mid-peripheral retina.", + "Recovery was partial following cessation of desferrioxamine.", + "Cessation of desferrioxamine occurred six weeks prior.", + "A follow-up SD-OCT showed multiple accumulated hyper-reflective deposits.", + "The hyper-reflective deposits were primarily in the choroid.", + "The hyper-reflective deposits were primarily in the retinal pigment epithelium (RPE).", + "The hyper-reflective deposits were primarily in the inner segment and outer segment (IS/OS) junction." + ] + }, + { + "id": "multiclinsum_test_87_en.txt", + "fulltext": "A 47-year-old male patient from Gaza was referred to our hospital due to body weakness, dysphagia and dysarthria of 14 days duration.\nHe was in his usual state of health until two weeks before admission when he started to complain of proximal muscle weakness that was increasing in severity in addition to fatigue, difficulty in speech and chocking episodes mainly triggered by liquids.\nIn Gaza hospital the doctors performed a brain and whole spine MRI which showed no abnormality. Furthermore, a lumbar puncture was done with normal results.\nDue to a progressive deterioration of his symptoms, as his weakness was so severe he was almost became quadriplegic, his case was referred to our hospital.\nAn NG tube was introduced due to his severe dysphagia and he was reevaluated with a thorough physical examination that showed: mild respiratory distress with a respiratory rate of 19 breaths/min, vitiligo over his entire body, weak gag reflex and nasal speech. The lower limb weakness was 1/5 bilaterally and the upper limb weakness was 2/5 with intact sensation and hyporeflexia.\nAn electromyography (EMG) and nerve conduction studies were also performed and showed a decrement in the muscle action-potential which lead to the suspicion of myasthenia gravis. Thus a serum anti-Ach receptor antibodies titer was done with positive results leading to the confirmation of this suspicion.\nDuring the patients’ time of hospitalization and evaluation, it was discovered that his fasting cortisol levels and TSH levels were low (TSH was 0.35 mU/L) whereas the T3 and T4 were high.\nSince the patient was found to have findings of three autoimmune diseases, autoimmune polyglandular syndrome was considered.\nSix sessions of plasmapheresis were done. The patient was also prescribed prednisolone pyridostigmine, azathioprine, vitamin D and thyroxin.\nAfter we started his treatment, the patient's muscle power started to improve (after the third session of plasmapheresis we could notice the improvement).\nIn addition, physiotherapy was recommended and after six sessions he was able to walk alone again, the NG tube was removed and he was started on oral feeding with a semi-solid diet.\nHe was discharged later after a good response to treatment with a good prognosis.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male from Gaza.", + "He was referred to the hospital due to body weakness, dysphagia, and dysarthria of 14 days duration.", + "He started to complain of proximal muscle weakness two weeks before admission.", + "He had difficulty in speech and choking episodes mainly triggered by liquids.", + "A brain and whole spine MRI in Gaza hospital showed no abnormality.", + "A lumbar puncture was done with normal results.", + "The weakness was so severe he was almost quadriplegic.", + "An NG tube was introduced due to severe dysphagia.", + "The physical examination showed mild respiratory distress with a respiratory rate of 19 breaths/min.", + "The physical examination showed vitiligo over his entire body.", + "The physical examination showed weak gag reflex and nasal speech.", + "The lower limb weakness was 1/5 bilaterally.", + "The upper limb weakness was 2/5.", + "An electromyography and nerve conduction studies showed a decrement in the muscle action-potential.", + "A serum anti-Ach receptor antibodies titer was done with positive results.", + "The fasting cortisol levels were low.", + "The TSH levels were low (0.35 mU/L).", + "The T3 and T4 were high.", + "Autoimmune polyglandular syndrome was considered.", + "Six sessions of plasmapheresis were done.", + "The patient was prescribed prednisolone, pyridostigmine, azathioprine, vitamin D, and thyroxin.", + "After the third session of plasmapheresis, the patient's muscle power started to improve.", + "Physiotherapy was recommended.", + "After six sessions, the patient was able to walk alone again.", + "The NG tube was removed.", + "He was started on oral feeding with a semi-solid diet.", + "He was discharged after a good response to treatment with a good prognosis." + ], + "summary": "We describe a case of a 47-year-old male patient presenting with weakness, difficulty swallowing (mainly liquids) and dysarthria. He was discovered to have low cortisol and TSH levels with high T4 and T3. These findings lead to the suspicion of a more complex disease process and through a thorough research of literature we discovered an association between myasthenia gravis and autoimmune polyglandular syndrome specifically type 2 which fits with our patients' presentation.", + "summary_subclaims": [ + "The patient is a 47-year-old male.", + "The patient presented with weakness.", + "The patient had difficulty swallowing, mainly with liquids.", + "The patient had dysarthria.", + "The patient had low cortisol levels.", + "The patient had low TSH levels.", + "The patient had high T4 levels.", + "The patient had high T3 levels.", + "These findings led to the suspicion of a more complex disease process.", + "Through a thorough research of literature, an association between myasthenia gravis and autoimmune polyglandular syndrome was discovered.", + "The association was specifically with type 2 autoimmune polyglandular syndrome.", + "The findings fit with the patient's presentation." + ] + }, + { + "id": "multiclinsum_test_2708_en.txt", + "fulltext": "A 56-year-old nonsmoking female presented with cough and chest tightness for 20 days with no past medical history. Vital signs were stable except diminished left lung sounds were noted in chest auscultation. She was then found to have a large left-sided pleural effusion in CT scan . Pleurocentisis revealed a clear fluid with yellow supernatant. The laboratory analysis of the fluid revealed the following: total protein, 41 g/L (serum protein, 67 g/L) and WBC count 3700 cells/ml (13% polymorphs and 87% lymphocytes). No organisms were seen on Gram stain, and no acid-fast bacilli ware seen on auramine stain. Cultures of the pleural effusion specimens and tumor markers were also negative. No malignant cells were seen, only mesothelial cells and lymphocytes. An enhanced CT scan performed one week later indicated a 6.2 cm × 4 cm oval-shaped lesion with significant enhancement, with maximum enhanced CT value approximately 125Hu . Magnetic resonance imaging (MRI) demonstrated a 6.2 cm × 4 cm well-defined, oval-shaped lesion with suspected invasion of intervertebral foramen, placed in the left costovertebral space . Before operation, it was diagnosed as neurogenic tumor.\nComplete resection was performed by video-assisted thoracoscopic surgery (VATS). On direct visualization, there was a lesion in the posterior mediastinum close to left paravertebral region with moderate hardness, not adhering to the surrounding spine, mediastinum or chest. The capsule was complete and the boundary was clear. Thoracoscopic resection was performed successfully, and the estimated intraoperative bleeding was 200 ml. The size of lesion was approximately 6 cm × 5 cm × 3.5 cm and was sent for routine pathology.\nHistopathology revealed a cavernous hemangioma composed of varying size and dilated cavernous sinuses, with an inner wall lined with vascular endothelium . In addition, makers including CD34, CD31 and SMA positive , Ki-67 staining was positive (2%). The patient’s post-operative recovery was uneventful and discharged from hospital on the third day after surgery. No recurrence was not noted at 14 month follow-up.", + "fulltext_subclaims": [ + "The patient is a 56-year-old nonsmoking female.", + "She had cough and chest tightness for 20 days.", + "She had no past medical history.", + "Vital signs were stable.", + "Diminished left lung sounds were noted in chest auscultation.", + "A CT scan showed a large left-sided pleural effusion.", + "Pleurocentesis revealed clear fluid with yellow supernatant.", + "The pleural fluid total protein was 41 g/L.", + "The serum protein was 67 g/L.", + "The pleural fluid WBC count was 3700 cells/ml.", + "The pleural fluid had 13% polymorphs.", + "The pleural fluid had 87% lymphocytes.", + "No organisms were seen on Gram stain.", + "No acid-fast bacilli were seen on auramine stain.", + "Cultures of the pleural effusion specimens were negative.", + "Tumor markers were negative.", + "No malignant cells were seen.", + "An enhanced CT scan showed a 6.2 cm × 4 cm oval-shaped lesion with significant enhancement.", + "The maximum enhanced CT value was approximately 125Hu.", + "MRI showed a 6.2 cm × 4 cm well-defined, oval-shaped lesion.", + "The lesion was suspected to invade the intervertebral foramen.", + "The lesion was located in the left costovertebral space.", + "The preoperative diagnosis was neurogenic tumor.", + "Complete resection was performed by video-assisted thoracoscopic surgery.", + "The lesion was in the posterior mediastinum close to the left paravertebral region.", + "The lesion had moderate hardness.", + "The lesion was not adhering to the surrounding spine, mediastinum, or chest.", + "The capsule was complete.", + "The boundary was clear.", + "Thoracoscopic resection was performed successfully.", + "The estimated intraoperative bleeding was 200 ml.", + "The lesion size was approximately 6 cm × 5 cm × 3.5 cm.", + "Histopathology revealed a cavernous hemangioma.", + "The hemangioma was composed of varying size and dilated cavernous sinuses.", + "The inner wall was lined with vascular endothelium.", + "CD34 was positive.", + "CD31 was positive.", + "SMA was positive.", + "Ki-67 staining was positive (2%).", + "The patient’s post-operative recovery was uneventful.", + "The patient was discharged on the third day after surgery.", + "No recurrence was noted at 14-month follow-up." + ], + "summary": "We report a case of a 56-year-old female who presented with cough and chest tightness and was found with a massive pleural effusion in chest CT. It was mistaken for a malignant pleural effusion. A posterior mediastinal lesion was observed after thoracic drainage and misdiagnosed again as neurofibroma. The lesion was resected and post-operative histopathology suggested that it was a cavernous hemangioma. Post-operative recovery was uneventful, and a follow-up examination nearly 14 months later showed the patient had no recurrence.", + "summary_subclaims": [ + "The patient was a 56-year-old female.", + "The patient presented with cough and chest tightness.", + "A chest CT showed a massive pleural effusion.", + "The pleural effusion was mistaken for a malignant pleural effusion.", + "A posterior mediastinal lesion was observed after thoracic drainage.", + "The lesion was misdiagnosed as neurofibroma.", + "The lesion was resected.", + "Post-operative histopathology suggested the lesion was a cavernous hemangioma.", + "Post-operative recovery was uneventful.", + "A follow-up examination nearly 14 months later showed the patient had no recurrence." + ] + }, + { + "id": "multiclinsum_test_1938_en.txt", + "fulltext": "A 71-year-old Norwegian woman was admitted to a local hospital in Oslo only hours after returning from a four-week holiday to Thailand. She presented with rapid onset of nausea and vomiting associated with fever and exhaustion, and had also been complaining of fatigue for two days. She was febrile (39.5 °C), and had a respiratory rate of 26 min−1. The leukocyte count was 12×109cells ml−1 and the C-reactive protein (CRP) level was 9 mg l−1. Intravenous antibiotic therapy with ampicillin and gentamicin was commenced on suspicion of urosepsis, but the patient’s condition rapidly deteriorated the same evening, with increasing confusion and speech disturbances; nuchal rigidity was noted. Bacterial meningitis now appeared likely. The patient was administered 4 g of ceftriaxone and transferred to Oslo University Hospital (OUS).\nUpon arrival at OUS, the patient had obvious nuchal rigidity and incoherent speech, and was motorically agitated and confused. The Glasgow Coma Scale (GCS) score was assessed as 12, but downgraded to 9 during the initial evaluation, at which point she was intubated.\nA cerebral computed tomography (CT) scan with angiography showed no acute ischaemic lesions, haemorrhage, arterial occlusion, stenosis, or aneurism. Lumbar puncture yielded cloudy cerebrospinal fluid (CSF) under increased pressure, with 0.1 mmol l−1 glucose (serum glucose 11.1 mmol l−1), a protein level of 6.9 g l−1, and a leukocyte count of 2115 mm−3 with 87.3 % neutrophils. No microbes were found on an acridine orange stain of CSF. A nigrosin stain did not show any cryptococci, although the examiner noted the presence of unidentified elements. Treatment was changed to meropenem and vancomycin since the infection was presumably acquired in a region endemic for highly resistant bacteria.\nThe patient’s condition deteriorated over the following twelve hours in spite of early initiation of antibiotic therapy. CRP increased to 269 mg l−1. A repeat cerebral CT scan showed general oedema, hydrocephalus and uncal herniation. External ventricular drainage with monitoring of intracerebral pressure (ICP) was established; ICP was measured to 80–90 mmHg. The patient remained unresponsive, with fixed dilated pupils. After observing that ICP remained consistently equal to mean arterial pressure, and examination indicated cessation of all cerebral functioning with no hope of improvement, active treatment was withdrawn three days after admission, and the patient was pronounced dead shortly thereafter. An autopsy was requested.", + "fulltext_subclaims": [ + "A 71-year-old Norwegian woman was admitted to a local hospital in Oslo.", + "She had returned from a four-week holiday to Thailand.", + "She presented with rapid onset of nausea and vomiting.", + "She had fever and exhaustion.", + "She had been complaining of fatigue for two days.", + "She was febrile (39.5 °C).", + "She had a respiratory rate of 26 min−1.", + "The leukocyte count was 12×109cells ml−1.", + "The C-reactive protein (CRP) level was 9 mg l−1.", + "Intravenous antibiotic therapy with ampicillin and gentamicin was commenced.", + "The patient’s condition rapidly deteriorated the same evening.", + "Bacterial meningitis now appeared likely.", + "The patient was administered 4 g of ceftriaxone.", + "The patient was transferred to Oslo University Hospital.", + "The patient had obvious nuchal rigidity.", + "The Glasgow Coma Scale (GCS) score was assessed as 12.", + "The GCS score was downgraded to 9 during the initial evaluation.", + "She was intubated.", + "A cerebral computed tomography (CT) scan with angiography showed no acute ischaemic lesions.", + "A cerebral CT scan showed no haemorrhage.", + "A cerebral CT scan showed no arterial occlusion.", + "A cerebral CT scan showed no stenosis.", + "A cerebral CT scan showed no aneurism.", + "Lumbar puncture yielded cloudy cerebrospinal fluid (CSF) under increased pressure.", + "CSF glucose was 0.1 mmol l−1.", + "Serum glucose was 11.1 mmol l−1.", + "CSF protein level was 6.9 g l−1.", + "CSF leukocyte count was 2115 mm−3.", + "CSF neutrophils were 87.3 %.", + "No microbes were found on an acridine orange stain of CSF.", + "A nigrosin stain did not show any cryptococci.", + "The infection was presumably acquired in a region endemic for highly resistant bacteria.", + "Treatment was changed to meropenem and vancomycin.", + "The patient’s condition deteriorated over the following twelve hours.", + "CRP increased to 269 mg l−1.", + "A repeat cerebral CT scan showed general oedema.", + "A repeat cerebral CT scan showed hydrocephalus.", + "A repeat cerebral CT scan showed uncal herniation.", + "External ventricular drainage with monitoring of intracerebral pressure (ICP) was established.", + "ICP was measured to 80–90 mmHg.", + "The patient remained unresponsive.", + "The patient had fixed dilated pupils.", + "Active treatment was withdrawn three days after admission.", + "The patient was pronounced dead shortly after treatment was withdrawn.", + "An autopsy was requested." + ], + "summary": "A fatal case of PAM in a previously healthy Norwegian woman, acquired during a holiday trip to Thailand, is described. Clinical findings were consistent with rapidly progressing meningoencephalitis. The cause of infection was discovered by chance, owing to the unexpected detection of N. fowleri DNA by a PCR assay targeting fungi. A conclusive diagnosis was established based on sequencing of N. fowleri DNA from brain biopsies, supported by histopathological findings. Nasal irrigation using contaminated tap water is suspected as the source of infection.", + "summary_subclaims": [ + "A fatal case of PAM in a previously healthy Norwegian woman is described.", + "The case was acquired during a holiday trip to Thailand.", + "Clinical findings were consistent with rapidly progressing meningoencephalitis.", + "The cause of infection was discovered by chance.", + "N. fowleri DNA was detected by a PCR assay targeting fungi.", + "A conclusive diagnosis was established based on sequencing of N. fowleri DNA from brain biopsies.", + "Histopathological findings supported the diagnosis.", + "Nasal irrigation using contaminated tap water is suspected as the source of infection." + ] + }, + { + "id": "multiclinsum_test_2093_en.txt", + "fulltext": "We present the case of a 72-year-old female GBC patient, who was admitted to our hospital due to chest tightness in September 2018.\nAfter examination, GBC was found to recur in situ, invading the duodenal descending part and causing intestinal fistula and hepatic colon adhesion. In addition, multiple metastases of the liver, lymph node metastasis around the head of the pancreas, severe anemia requiring weekly blood transfusion, and symptoms of heart failure were noted.\nIn December 2017, the 72-year old Chinese patient underwent IRE following diagnosis as GBC (T3N1M0 stage IIIA) based on computed tomography (CT) imaging and pathological findings of GBC (8.0 cm × 3.9 cm) with multiple hilar lymph node invasion (max 4.7 cm × 3.6 cm). She had elevated levels of a variety of serum tumor markers, including CA19-9 (2556 U/mL) and CEA (607.6 ng/mL).\nAfter IRE ablation of the gallbladder and hilar lymph nodes, oral tegafur (20 mg bid) chemotherapy was administered for 9 mo. CT re-examination in April 2018 showed liquefactive necrosis at the ablation site. During the treatment period, the patient received intermittent red blood cell (RBC) infusions as supportive care for repeated episodes of anemia.\nAccompanied by a progressive increase in pain in the upper right abdomen, a large area of adhesion between the gallbladder and the descending and horizontal segments of the duodenum was found in addition to compression of the inferior vena cava (October 6, 2018).\nShe had elevated levels of a variety of serum tumor markers, including CA19-9 (88.18 U/mL), AFP (14.11 IU/mL), and CEA (39.68 ng/mL) in September, 2018.\nAfter 2 wk of blood transfusions and anti-infective treatment, CT examination again revealed a bladder tumor (6.3 cm × 4.9 cm), with an adjacent descending duodenal fistula, multiple spotted high-density lesions in the liver parenchyma, and dilatation and gas accumulation in the intrahepatic and extrahepatic bile ducts. Enlarged lymph nodes (2.7 cm × 2.1 cm) were visible around the pancreatic head.", + "fulltext_subclaims": [ + "The patient was a 72-year-old female.", + "The patient was admitted to the hospital due to chest tightness in September 2018.", + "Gallbladder cancer was found to recur in situ.", + "The recurrent gallbladder cancer invaded the duodenal descending part.", + "The recurrent gallbladder cancer caused intestinal fistula.", + "The recurrent gallbladder cancer caused hepatic colon adhesion.", + "Multiple metastases of the liver were noted.", + "Lymph node metastasis around the head of the pancreas was noted.", + "The patient had severe anemia requiring weekly blood transfusion.", + "The patient had symptoms of heart failure.", + "In December 2017, the patient underwent IRE.", + "The patient was diagnosed as GBC (T3N1M0 stage IIIA) based on CT imaging and pathological findings.", + "The gallbladder tumor measured 8.0 cm × 3.9 cm.", + "Multiple hilar lymph node invasion was present.", + "The largest hilar lymph node measured 4.7 cm × 3.6 cm.", + "The patient had elevated CA19-9 levels (2556 U/mL).", + "The patient had elevated CEA levels (607.6 ng/mL).", + "After IRE ablation of the gallbladder and hilar lymph nodes, oral tegafur (20 mg bid) chemotherapy was administered for 9 mo.", + "CT re-examination in April 2018 showed liquefactive necrosis at the ablation site.", + "The patient received intermittent red blood cell infusions as supportive care.", + "In October 2018, a large area of adhesion between the gallbladder and the descending and horizontal segments of the duodenum was found.", + "In September 2018, the patient had elevated CA19-9 levels (88.18 U/mL).", + "In September 2018, the patient had elevated CEA levels (39.68 ng/mL).", + "In September 2018, the patient had elevated AFP levels (14.11 IU/mL).", + "After 2 wk of blood transfusions and anti-infective treatment, CT examination revealed a bladder tumor (6.3 cm × 4.9 cm).", + "CT examination revealed an adjacent descending duodenal fistula.", + "CT examination revealed multiple spotted high-density lesions in the liver parenchyma.", + "CT examination revealed dilatation and gas accumulation in the intrahepatic and extrahepatic bile ducts.", + "Enlarged lymph nodes (2.7 cm × 2.1 cm) were visible around the pancreatic head." + ], + "summary": "The patient refused other treatments and began daily hydrogen inhalation therapy. After 1 mo of treatment, the gallbladder and liver tumors continued to progress, and intestinal obstruction occurred. After continuous hydrogen therapy and symptomatic treatments including gastrointestinal decompression and intravenous nutrition support, the intestinal obstruction was gradually relieved. Three months after hydrogen therapy, the metastases in the abdominal cavity gradually reduced in size, her anemia and hypoalbuminemia were corrected, lymphocyte and tumor marker levels returned to normal, and the patient was able to resume normal life.", + "summary_subclaims": [ + "The patient refused other treatments and began daily hydrogen inhalation therapy.", + "After 1 mo of treatment, the gallbladder and liver tumors continued to progress.", + "Intestinal obstruction occurred.", + "After continuous hydrogen therapy and symptomatic treatments including gastrointestinal decompression and intravenous nutrition support, the intestinal obstruction was gradually relieved.", + "Three months after hydrogen therapy, the metastases in the abdominal cavity gradually reduced in size.", + "Her anemia and hypoalbuminemia were corrected.", + "Lymphocyte and tumor marker levels returned to normal.", + "The patient was able to resume normal life." + ] + }, + { + "id": "multiclinsum_test_2910_en.txt", + "fulltext": "A 58-year-old female had a three year-history of multiple stress fractures and muscle weakness. Her medical history included well-controlled type 2 diabetes (HbA1c 43 mmol/mol) for nearly 20 years. Her BMI was 39 kg/m2 and she was on metformin, long-acting insulin and pioglitazone. She was a current smoker with a smoking history of 27 pack years and her dietary calcium intake was considered normal. Skeletal growth had been normal, and she had not suffered from bone fractures or abnormal skeletal pains previously. She did not have a family history of skeletal, metabolic or hormonal disorders.\nThree years prior to diagnosis the patient presented with multiple fragility fractures and increasing bone pain. Fractures were found in the vertebrae , right femur, sacrum and lateral condyle of the right tibia, and in the left talus. She complained of progressive muscle weakness and diffuse bone pains in her back and lower extremities.\nOne year later, dual-energy X-ray absorptiometry (DXA) demonstrated osteopenic bone mineral density (T-scores of lumbar vertebrae 3-4 and the femoral neck were -0.8 SD, and -2.3 SD, respectively). Basic biochemistry in primary care was unremarkable (data not shown). Pioglitazone treatment, initiated four years before the first fragility fracture, was suspected to underlie the multiple, low-intensity fractures and therefore discontinued. At this point, type 2 diabetes was considered as another predisposing factor.\nDuring the year before the diagnosis, she suffered from a stress fracture of the left femur with significant dislocation , which was treated with total hip arthroplasty, as well as a stress fracture of the right femur that was treated with an intramedullary nail . Within the next months, she also suffered from stress fractures of the right distal femur, tibia and humerus.\nA year before correct diagnosis of TIO, teriparatide, calcium carbonate (1000 mg daily) and cholecalciferol (20 µg daily) supplementations were initiated to enhance recovery of bone strength after pioglitazone treatment.\nThe patient was referred to the University Hospital Endocrine Unit. At this time point, the patient had not been able to walk for two years, was bedridden and had lost 30 kg of weight (from 106 to 78kg), and she needed constant pain medication (oxycodone 50 mg, gabapentin 1800 mg and paracetamol 3 grams daily). Biochemical tests revealed hypophosphatemia, combined with high serum FGF23-concentration (C-terminal, EIA-method, MVZ Labor Dr. Limbach & Kollegen, Heidelberg, Germany), inappropriately normal 24-hour urinary phosphate secretion, and increased serum alkaline phosphatase concentration . Alphacalcidol (0.25 µg twice daily) and phosphate supplementation (Phosphate Sandoz 500 mg twice daily, reduced dose due to diarrhea) were started. Calcium carbonate 1000 mg and cholecalciferol 20 µg daily were continued and teriparatide was discontinued. A bone biopsy from the iliac crest demonstrated osteomalacia. Genetic testing for hypophosphatemia [mutations in the DMP-1, ENPP1, FGF23, PHEX and SLC34A3 genes ] was negative. Computed tomography (CT) of the thorax and abdomen revealed no tumors. An additional, complete physical examination revealed a palpable mass in the right mandible. Ultrasound and CT confirmed a tumor with invasive growth in the right mandible . Cytologic analysis of a fine needle aspiration taken from the tumor demonstrated myoepithelial-like cells.\nAfter the diagnosis was confirmed, the tumor of the right mandible was operated. Histopathological examination of formalin-fixed and paraffin-embedded slides demonstrated a 2.6 cm phosphaturic mesenchymal tumor with multinucleated, osteoclast-like cells , with minimum tumor free resection margins of 0.5 mm. The Ki-67 proliferation index in hot spots was 10-15%. Immunohistochemical studies showed positive vimentin staining but negative CD34, EMA, and CKPAN stainings, compatible with a phosphaturic mesenchymal tumor and the diagnosis of TIO . The histologic samples were re-evaluated by an expert pathologist in the National Institutes of Health, USA.\nPostoperatively, the patient needed prolonged treatment of 10 days in the intensive care unit. Both intravenous and p.o. phosphate supplementations were warranted to correct for severe hypophosphatemia . After surgery, the concentration of serum ionized calcium remained in the normal range, 1.16-1.25 mmol/l (reference range 1.15-1.30 mmol/l). Administration of calcium carbonate 1000 mg and cholecalciferol 20 µg daily was continued. Due to muscle weakness, the patient was dependent on mechanical ventilation for four days. Thereafter, she needed continuous positive airway pressure (CPAP) through a tracheostomy. During that time, to maintain sufficient blood pressure levels, norepinephrine infusion had to be maintained for one week after surgery. She was on enteral nutrition during the postoperative days 1-11 (1500 kcal daily from third postoperative day). On the third postoperative day, the patient presented with respiratory alkalosis for six hours after fiberoptic bronchoscopy, with a pH of 7.52-7.60 and low/normal pCO2 (3.6-4.9 kPa), and elevated pO2 (13.2-59.8 kPa), base excess (BE) (2.5-5.7 mmol/l) and bicarbonate (HCO3) concentrations (27-30 mmol/l) (reference ranges 7.35-7.45, 4.5-6.0 kPa, 9.3-12.3 kPa, -2.5-2.5 mmol/l and 22-24 mmol/l, respectively). From the fourth postoperative day onwards, arterial pH remained within normal range. The patient was decanylated one week postoperatively . She received subcutaneous short-acting insulin (4-12 units daily) for hyperglycaemia.\nPhosphate supplementations were administered for eight weeks. The patient received oxandrolone for one week because of extreme weakness and lack of spontaneous respiratory activity in order to improve muscle function and the recovery of lean body mass . Skeletal and limb pains relieved soon, and muscle weakness alleviated within the succeeding months. The patient was able to take a few steps after four months of rehabilitation.\nAfter two years of rehabilitation, the patient was able to walk 100 meters with a walker and shorter distances without any help. She has not suffered from any further fractures or bone pains. After surgery, serum phosphate concentration has remained normal. Serum FGF23 concentrations decreased immediately after the operation and have remained slightly increased . Due to the vertebral fractures, DXA of the spine was unreliable.", + "fulltext_subclaims": [ + "The patient was a 58-year-old female.", + "She had a three year-history of multiple stress fractures.", + "She had muscle weakness.", + "Her medical history included well-controlled type 2 diabetes.", + "Her HbA1c was 43 mmol/mol.", + "Her BMI was 39 kg/m2.", + "She was on metformin, long-acting insulin, and pioglitazone.", + "She was a current smoker with a smoking history of 27 pack years.", + "She had not suffered from bone fractures or abnormal skeletal pains previously.", + "She did not have a family history of skeletal, metabolic, or hormonal disorders.", + "Three years prior to diagnosis, the patient presented with multiple fragility fractures.", + "Fractures were found in the vertebrae, right femur, sacrum, lateral condyle of the right tibia, and left talus.", + "She complained of progressive muscle weakness.", + "She had diffuse bone pains in her back and lower extremities.", + "DXA demonstrated osteopenic bone mineral density.", + "The T-scores of the lumbar vertebrae 3-4 were -0.8 SD.", + "The T-scores of the femoral neck were -2.3 SD.", + "Pioglitazone treatment was suspected to underlie the multiple, low-intensity fractures.", + "Pioglitazone was discontinued.", + "Type 2 diabetes was considered as another predisposing factor.", + "During the year before the diagnosis, she suffered from a stress fracture of the left femur with significant dislocation.", + "The left femur fracture was treated with total hip arthroplasty.", + "A stress fracture of the right femur was treated with an intramedullary nail.", + "She also suffered from stress fractures of the right distal femur, tibia, and humerus.", + "A year before correct diagnosis of TIO, teriparatide, calcium carbonate, and cholecalciferol supplementations were initiated.", + "The patient was referred to the University Hospital Endocrine Unit.", + "At this time point, the patient had not been able to walk for two years.", + "She was bedridden.", + "She had lost 30 kg of weight.", + "She needed constant pain medication.", + "Biochemical tests revealed hypophosphatemia.", + "Serum FGF23 concentration was high.", + "24-hour urinary phosphate secretion was inappropriately normal.", + "Serum alkaline phosphatase concentration was increased.", + "Alphacalcidol and phosphate supplementation were started.", + "Calcium carbonate and cholecalciferol were continued.", + "Teriparatide was discontinued.", + "A bone biopsy from the iliac crest demonstrated osteomalacia.", + "Genetic testing for hypophosphatemia was negative.", + "Computed tomography of the thorax and abdomen revealed no tumors.", + "An additional physical examination revealed a palpable mass in the right mandible.", + "Ultrasound and CT confirmed a tumor with invasive growth in the right mandible.", + "Cytologic analysis of a fine needle aspiration demonstrated myoepithelial-like cells.", + "The tumor of the right mandible was operated.", + "Histopathological examination demonstrated a 2.6 cm phosphaturic mesenchymal tumor.", + "The tumor had multinucleated, osteoclast-like cells.", + "The Ki-67 proliferation index in hot spots was 10-15%.", + "Immunohistochemical studies showed positive vimentin staining.", + "Immunohistochemical studies showed negative CD34, EMA, and CKPAN stainings.", + "The diagnosis was compatible with a phosphaturic mesenchymal tumor.", + "The histologic samples were re-evaluated by an expert pathologist in the National Institutes of Health, USA.", + "The patient needed prolonged treatment of 10 days in the intensive care unit.", + "Both intravenous and p.o. phosphate supplementations were warranted.", + "After surgery, the concentration of serum ionized calcium remained in the normal range.", + "Calcium carbonate and cholecalciferol were continued.", + "The patient was dependent on mechanical ventilation for four days.", + "She needed continuous positive airway pressure through a tracheostomy.", + "Norepinephrine infusion had to be maintained for one week after surgery.", + "She was on enteral nutrition during the postoperative days 1-11.", + "On the third postoperative day, the patient presented with respiratory alkalosis.", + "Arterial pH remained within normal range from the fourth postoperative day onwards.", + "The patient was decannulated one week postoperatively.", + "She received subcutaneous short-acting insulin for hyperglycaemia.", + "Phosphate supplementations were administered for eight weeks.", + "The patient received oxandrolone for one week.", + "Skeletal and limb pains relieved soon.", + "Muscle weakness alleviated within the succeeding months.", + "The patient was able to take a few steps after four months of rehabilitation.", + "After two years of rehabilitation, the patient was able to walk 100 meters with a walker.", + "She has not suffered from any further fractures or bone pains.", + "After surgery, serum phosphate concentration has remained normal.", + "Serum FGF23 concentrations decreased immediately after the operation.", + "DXA of the spine was unreliable due to vertebral fractures." + ], + "summary": "The current case describes severe fragility fractures in a 58-year-old woman, who lost her ability to walk and was bedridden for two years. First, the initial diagnostic laboratory work-up did not include serum phosphorus measurements, second, the suspicion of adverse effects of pioglitazone as an underlying cause delayed correct diagnosis for at least two years. After biochemical discovery of hyperphosphaturic hypophosphatemia at a tertiary referral centre, a FGF23-producing tumor of the mandible was discovered on physical examination, and then surgically removed. Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for ventilation support, intensive care and phosphate supplementation. After two years of rehabilitation, the patient was able to walk short distances. The tumor has not recurred, and serum phosphate concentration has remained within normal limits during 3.5 years of follow-up.", + "summary_subclaims": [ + "The current case describes severe fragility fractures in a 58-year-old woman.", + "The patient lost her ability to walk and was bedridden for two years.", + "The initial diagnostic laboratory work-up did not include serum phosphorus measurements.", + "The suspicion of adverse effects of pioglitazone as an underlying cause delayed correct diagnosis for at least two years.", + "After biochemical discovery of hyperphosphaturic hypophosphatemia at a tertiary referral centre, a FGF23-producing tumor of the mandible was discovered on physical examination.", + "The tumor was surgically removed.", + "Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for ventilation support.", + "Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for intensive care.", + "Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for phosphate supplementation.", + "After two years of rehabilitation, the patient was able to walk short distances.", + "The tumor has not recurred.", + "Serum phosphate concentration has remained within normal limits during 3.5 years of follow-up." + ] + }, + { + "id": "multiclinsum_test_2139_en.txt", + "fulltext": "At the Vascular Surgery Department of our Institution, we examined a male patient (42 years old) who presented with a scrotal tumefaction. This tumefaction was approximately 15 × 17 cm in size and had been progressively developing after surgery for the removal of a left-side testicular angioma. Secondary sterility had occurred, as suggested by a spermiogram that revealed azoospermia (<20,000 spermatozoa/mL). Ultrasonographic test results performed during hospitalization revealed a diagnosis of scrotal arteriovenous malformation and a small fluid slope in the left tunica vaginalis; the testicles appeared to be regular in shape and had an echographic pattern. The patient underwent an angio-computed tomography (CT) of spiral multislides of the abdominal aorta and the lower limbs. The exam results indicated the presence of a raw agglomerate of enlarged blood vessels located in the left-1 side scrotal portion that was causing a contralateral dislocation of the right testicle . The mass was supplied by four arterial confluences: two from the superficial femoral arteries and two from the hypogastric arteries through the bilateral penile arteries. In addition, the scrotal venous system showed varicosity and congestion of the bilateral common femoral veins, most likely due to an arteriovenous shunt. It was decided that the malformation should be treated on the basis of a protocol involving endovascular arterial embolization with Glubran 2. The patient, after signing his informed consent, underwent a selective catheterization of the arterial ramifications via a left-side percutaneous transfemoral approach originating from the left femoral and left hypogastric arteries. A postprocedural angiographic check indicated devascularization of the lesion and a slight reduction in the size of the scrotal tumefaction. Two days after the procedure, a second embolization was performed via a left transfemoral approach to obtain a further reduction in the vascularization of the tumefaction, combined with the selective catheterization of the arterial ramifications coming from the right femoral and right hypogastric arteries . After 72 h from the embolization a skin necrosis on the hemiscrotum due to ischemia of the area previously supplied by the anomalous blood vessel was present. To avoid the development of a serious form of infected necrosis, such as Fournier’s gangrene, the patient underwent repeat surgery and debridement of the wide necrotic skin tissue (A B). During the following days, the patient received daily medications at the lesion site, coupled with endovenous antibiotic therapy. The agglomerate progressively decreased in size, and the necrotic area increased its demarcation. The patient was discharged from the hospital with antibiotic therapy 20 days after the first embolization procedure. In addition, he was prescribed daily medications, and he underwent subsequent plastic surgery for scrotal reconstruction. The spermiogram result showed azoospermia in both testicles.", + "fulltext_subclaims": [ + "The patient was a 42-year-old male.", + "The patient presented with a scrotal tumefaction.", + "The scrotal tumefaction was approximately 15 × 17 cm in size.", + "The tumefaction had been progressively developing after surgery for the removal of a left-side testicular angioma.", + "A spermiogram revealed azoospermia (<20,000 spermatozoa/mL).", + "Ultrasonographic test results revealed a diagnosis of scrotal arteriovenous malformation.", + "The testicles appeared to be regular in shape.", + "The patient underwent an angio-computed tomography of spiral multislides of the abdominal aorta and the lower limbs.", + "The CT exam indicated the presence of a raw agglomerate of enlarged blood vessels located in the left-side scrotal portion.", + "The mass was supplied by four arterial confluences.", + "The scrotal venous system showed varicosity and congestion of the bilateral common femoral veins.", + "The malformation was treated with endovascular arterial embolization with Glubran 2.", + "The patient underwent a selective catheterization of the arterial ramifications via a left-side percutaneous transfemoral approach.", + "A postprocedural angiographic check indicated devascularization of the lesion.", + "A second embolization was performed via a left transfemoral approach.", + "After 72 h from the embolization, skin necrosis on the hemiscrotum due to ischemia was present.", + "The patient underwent repeat surgery and debridement of the wide necrotic skin tissue.", + "The patient received daily medications at the lesion site.", + "The patient received endovenous antibiotic therapy.", + "The agglomerate progressively decreased in size.", + "The necrotic area increased its demarcation.", + "The patient was discharged from the hospital 20 days after the first embolization procedure.", + "The patient underwent subsequent plastic surgery for scrotal reconstruction.", + "The spermiogram result showed azoospermia in both testicles." + ], + "summary": "The two-phase strategy adopted in that case permitted complete treatment of a large-sized malformation that was served by 4 main blood confluences.", + "summary_subclaims": [ + "The two-phase strategy permitted complete treatment of a large-sized malformation.", + "The malformation was served by 4 main blood confluences." + ] + }, + { + "id": "multiclinsum_test_2960_en.txt", + "fulltext": "A 62-year-old woman presented to our emergency department with progressive shortness of breath and cough for 3 days. Initial physical examination revealed that the patient was tachypneic, and vital signs were temperature 37.7° C, heart rate 110 beats per minute, blood pressure 100/55 mm Hg, and oxygen saturation 85% on room air. Chest auscultation revealed clear lung fields and a pansystolic murmur over the right lower parasternal area. Her history was significant for end-stage renal disease managed with regular haemodialysis by a right-sided double-lumen tunnelled catheter. At this time, the differential diagnosis included pulmonary embolism, fluid overload, and SARS-CoV2 infection.\nComputed tomography pulmonary angiography was performed and revealed bilateral segmental and subsegmental pulmonary embolism . Polymerase chain reaction testing for SARS-CoV2 was negative. The patient was admitted to the intensive care unit, and intravenous heparin infusion 18 U/kg/h was initiated and up titrated till 28 U/kg/h to achieve APTT of 80 ms. She subsequently stabilized. However, 2 days later, she suddenly developed hypotension with blood pressure of 70/40 mm Hg.\nTransthoracic Echocardiography (TTE) revealed a dilated right-side, significant tricuspid regurgitation, pulmonary artery systolic pressure was 56 mmHg with normal aortic valve morphology and flow. Electrocardiography showed ST-segment elevation in the inferolateral leads . Laboratory studies showed a high-sensitive cardiac troponin-T values that increased from 5000 ng/mL to 21 957 ng/mL (reference range: 0–18 ng/mL). The patient was immediately moved to the catheterization laboratory for coronary angiography, which revealed total occlusion of the posterior descending artery. Multiple attempts for aspiration and balloon inflation to restore the flow failed. The patient then was relocated to the ICU.\nTwo days later, the patient suddenly developed complete heart block, which required temporary pacemaker insertion. In addition, she became feverish with a temperature of 38.9° C, and pus oozing from the haemodialysis catheter site was observed. Line sepsis was diagnosed, and the catheter was removed with a large amount of pus. Subsequent blood culture and catheter tip culture revealed Methicillin-resistant Staphylococcus aureus.\nTransesophageal echocardiography (TOE) was performed and revealed aortic valve vegetations with acute severe aortic regurgitation, right atrial appendage mass, and patent foramen ovale. A multidisciplinary team meeting was urgently done, and the decisions were immediate initiation of antibiotics and urgent preparation for surgery. Intravenous vancomycin 30 mg/kg/d in three doses was initiated.\nAfter 90 min, the patient developed a disturbed level of consciousness and resistant shock. She was mechanically ventilated, intravenous inotropes were increased to the maximum dose and extracorporeal membrane oxygenation system was inserted. The patient continued to rapidly deteriorate, and then died.", + "fulltext_subclaims": [ + "A 62-year-old woman presented to the emergency department with progressive shortness of breath and cough for 3 days.", + "Initial physical examination revealed the patient was tachypneic.", + "Oxygen saturation was 85% on room air.", + "Chest auscultation revealed clear lung fields.", + "The differential diagnosis included pulmonary embolism.", + "Computed tomography pulmonary angiography revealed bilateral segmental and subsegmental pulmonary embolism.", + "Polymerase chain reaction testing for SARS-CoV2 was negative.", + "Intravenous heparin infusion 18 U/kg/h was initiated.", + "The heparin infusion was up titrated till 28 U/kg/h to achieve APTT of 80 ms.", + "Two days later, the patient suddenly developed hypotension with blood pressure of 70/40 mm Hg.", + "Transthoracic Echocardiography revealed a dilated right-side.", + "Electrocardiography showed ST-segment elevation in the inferolateral leads.", + "High-sensitive cardiac troponin-T values increased from 5000 ng/mL to 21 957 ng/mL.", + "Coronary angiography revealed total occlusion of the posterior descending artery.", + "Multiple attempts for aspiration and balloon inflation to restore the flow failed.", + "The patient was relocated to the ICU.", + "Two days later, the patient suddenly developed complete heart block.", + "Temporary pacemaker insertion was performed.", + "Pus oozing from the haemodialysis catheter site was observed.", + "Line sepsis was diagnosed.", + "The catheter was removed with a large amount of pus.", + "Subsequent blood culture and catheter tip culture revealed Methicillin-resistant Staphylococcus aureus.", + "Transesophageal echocardiography revealed aortic valve vegetations.", + "A multidisciplinary team meeting was urgently done.", + "Intravenous vancomycin 30 mg/kg/d in three doses was initiated.", + "After 90 min, the patient developed a disturbed level of consciousness.", + "Extracorporeal membrane oxygenation system was inserted.", + "The patient continued to rapidly deteriorate.", + "The patient died." + ], + "summary": "A 62-year-old woman with end-stage renal disease on haemodialysis presented with shortness of breath and desaturation. Her history was significant for end-stage renal disease managed with regular haemodialysis by a right-sided double-lumen tunnelled catheter. An initial diagnosis was made of pulmonary embolism, and management with intravenous heparin was initiated. She subsequently developed inferolateral ST-elevation myocardial infarction, and treatment with percutaneous coronary intervention to the posterior descending artery failed. Then, the patient developed complete heart block, aortic valve vegetation, acute severe aortic regurgitation, and shock.", + "summary_subclaims": [ + "The patient is a 62-year-old woman.", + "She has end-stage renal disease.", + "She is on haemodialysis.", + "She presented with shortness of breath.", + "She had desaturation.", + "Her history was significant for end-stage renal disease.", + "She was managed with regular haemodialysis.", + "She had a right-sided double-lumen tunnelled catheter.", + "An initial diagnosis was made of pulmonary embolism.", + "Management with intravenous heparin was initiated.", + "She subsequently developed inferolateral ST-elevation myocardial infarction.", + "Treatment with percutaneous coronary intervention to the posterior descending artery failed.", + "The patient developed complete heart block.", + "She had aortic valve vegetation.", + "She had acute severe aortic regurgitation.", + "She developed shock." + ] + }, + { + "id": "multiclinsum_test_2916_en.txt", + "fulltext": "A 57-year-old man with a previous history of hypertension and stroke was referred to our hospital with transient episodes of dizziness, diplopia, and left-side numbness for 2 weeks. Each episode lasted for 5 to 30 min without unconsciousness and then completely relieved. After the onset of these symptoms, the patient was first admitted to a local hospital where he received optimal medical therapy including dual antiplatelet agents (aspirin 100 mg/day and clopidogrel 75 mg/day) and risk factor modifications. However, the patient still experienced another two episodes of TIAs under optimal medical treatment. His radiological examination in the local hospital suggested multifocal intracranial and extracranial atherosclerosis (data not shown). The patient was, therefore, transferred to our hospital for further management. After admission, the patient underwent a series of diagnostic evaluations. Neurological examination showed no permanent neurological disability with a National Institute of Health Stroke Scale score of 0. Laboratory tests including blood routine examination, hepatorenal function, lipid profile, homocysteine level, glycosylated hemoglobin level, and coagulation function were all normal. Multimodal computed tomography (CT) was also performed, and non-contrast CT demonstrated a hypodensity lesion in the left thalamus . CT angiography (CTA) showed proximal non-tapered occlusion and distal severe stenosis of the left VA , and that the right VA did not converge with the left VA into the basilar artery . Based on these findings, the diagnosis of TIA due to VA occlusion was made. Since the patient had recurrent neurological symptoms despite optimal medical management, endovascular recanalization of the left VA was recommended.\nThe procedure was performed under local anesthesia. After the femoral artery puncture, an 8F artery sheath was inserted, and the patient was intra-arterially heparinized to achieve an activated clotting time of more than 250 s. An 8F guiding catheter (Cordis, Florida, USA) and a 5F diagnostic catheter (Cordis, Florida, USA) were delivered to the left subclavian artery proximal to the VA ostium under the guidance of a 0.035-in loach guidewire (Terumo, Tokyo, Japan). After retracting the loach guidewire, an initial digital subtraction angiography (DSA) was performed via the diagnostic catheter, which demonstrated non-tapered occlusion of the V1 segment and severe stenosis (approximately 80%) of the V4 segment of the left VA. In the beginning, multiple attempts were performed with the coaxial assembly of a PT 0.014-in micro guidewire (Boston Scientific, Boston, USA) and an Excelsior SL-10 microcatheter (Stryker, Michigan, USA) to facilitate navigation across the occluded segment but failed . At the moment, robust deep cervical collateral to the distal V3 segment of the left VA and a tapered stump of the distal part of the occluded segment were noted . Therefore, the exchange of a Synchro 0.014-in micro guidewire (Stryker, Michigan, USA) was performed to reach the distal V3 segment through the left deep cervical artery, which then reversely traversed the occluded segment to the left subclavian artery successfully (, ). A Neuro RX 2.75 × 15 mm balloon (Sinomed, Tianjin, China) was subsequently advanced to the VA ostium along the micro guidewire to dilate the occluded segment . After balloon dilation, the occluded segment was successfully recanalized but remained in severe stenosis . We retracted the balloon and advanced a 5F intermediate catheter (Tonbridge, Zhuhai, China) with a Transend 0.014-in micro guidewire inside (Stryker, Michigan, USA), which passed the recanalized segment and was placed in the left VA and posterior cerebral artery. DSA revealed severe stenosis of the V4 segment and antegrade filling of the basilar artery and both posterior cerebral arteries . Under the guidance of an angiogram, a NOVA 4.0 × 15 mm balloon-expandable stent (Sinomed, Tianjin, China) was implemented in the stenotic segment (, ). To prevent restenosis of the V1-V2 segment, a RX 4.0 × 18 mm balloon-expandable stent (Abbott, California, USA) and a Bridge 4.0 × 18 mm rapamycin drug-eluting stent (Microport, Shanghai, China) were consecutively implanted in the recanalized segment . Finally, the 8F guiding catheter, intermediate catheter, and micro guidewire were carefully retracted.\nAfter the procedure, the patient underwent a repeated CTA examination, which indicated successful recanalization of the left VA . Dual antiplatelet therapy and risk factor control strategies were continued in this patient. During the follow-up of 3 months, the patient reported no neurological symptoms. summarizes the timeline of the present case.", + "fulltext_subclaims": [ + "The patient is a 57-year-old man.", + "He has a previous history of hypertension.", + "He has a previous history of stroke.", + "He was referred to the hospital with transient episodes of dizziness, diplopia, and left-side numbness.", + "The episodes lasted for 5 to 30 minutes.", + "The episodes were without unconsciousness.", + "The episodes were completely relieved.", + "The patient was first admitted to a local hospital.", + "He received dual antiplatelet agents (aspirin 100 mg/day and clopidogrel 75 mg/day).", + "He received risk factor modifications.", + "He still experienced two episodes of TIAs under optimal medical treatment.", + "Radiological examination suggested multifocal intracranial and extracranial atherosclerosis.", + "The patient was transferred to the hospital for further management.", + "Neurological examination showed no permanent neurological disability.", + "The National Institute of Health Stroke Scale score was 0.", + "Laboratory tests including blood routine examination, hepatorenal function, lipid profile, homocysteine level, glycosylated hemoglobin level, and coagulation function were all normal.", + "Non-contrast CT demonstrated a hypodensity lesion in the left thalamus.", + "CT angiography showed proximal non-tapered occlusion and distal severe stenosis of the left VA.", + "The right VA did not converge with the left VA into the basilar artery.", + "The diagnosis was TIA due to VA occlusion.", + "Endovascular recanalization of the left VA was recommended.", + "The procedure was performed under local anesthesia.", + "An 8F artery sheath was inserted after femoral artery puncture.", + "The patient was intra-arterially heparinized to achieve an activated clotting time of more than 250 s.", + "An 8F guiding catheter and a 5F diagnostic catheter were delivered to the left subclavian artery.", + "Initial DSA demonstrated non-tapered occlusion of the V1 segment and severe stenosis of the V4 segment of the left VA.", + "Multiple attempts with a coaxial assembly to navigate across the occluded segment failed.", + "Robust deep cervical collateral to the distal V3 segment of the left VA was noted.", + "A tapered stump of the distal part of the occluded segment was noted.", + "A Synchro 0.014-in micro guidewire was exchanged to reach the distal V3 segment through the left deep cervical artery.", + "The guidewire reversely traversed the occluded segment to the left subclavian artery.", + "A Neuro RX 2.75 × 15 mm balloon was advanced to the VA ostium.", + "The occluded segment was successfully recanalized.", + "The occluded segment remained in severe stenosis after balloon dilation.", + "A 5F intermediate catheter was advanced to the left VA and posterior cerebral artery.", + "DSA revealed severe stenosis of the V4 segment.", + "A NOVA 4.0 × 15 mm balloon-expandable stent was implemented in the stenotic segment.", + "A RX 4.0 × 18 mm balloon-expandable stent and a Bridge 4.0 × 18 mm rapamycin drug-eluting stent were consecutively implanted.", + "The 8F guiding catheter, intermediate catheter, and micro guidewire were retracted.", + "A repeated CTA examination indicated successful recanalization of the left VA.", + "Dual antiplatelet therapy and risk factor control strategies were continued.", + "During the follow-up of 3 months, the patient reported no neurological symptoms." + ], + "summary": "The present case was a patient with VA ostial occlusion with non-tapered stump and distal severe stenosis of the left VA who had recurrent posterior circulation transit ischemic attacks under optimal medical therapy. CT angiography demonstrated proximal non-tapered occlusion and distal severe stenosis of the left VA, and that the right VA did not converge with the left VA into basilar artery. Endovascular treatment was recommended and performed on this patient. However, antegrade endovascular recanalization of the left VA origin occlusion failed because the micro guidewire was unable to traverse the occluded segment. Fortunately, robust collateral from the deep cervical artery to the V3 segment of the left VA developed, in which we advanced the micro guidewire to the V3 segment of the left VA and reversely passed the micro guidewire through the occluded segment. Then, the occlusion and stenosis of the left VA were successfully resolved with angioplasty and stenting. After the procedure, the patient reported no neurological symptoms under medical therapy during 3-month follow-up.", + "summary_subclaims": [ + "The patient had VA ostial occlusion with non-tapered stump and distal severe stenosis of the left VA.", + "The patient had recurrent posterior circulation transient ischemic attacks under optimal medical therapy.", + "CT angiography demonstrated proximal non-tapered occlusion and distal severe stenosis of the left VA.", + "The right VA did not converge with the left VA into basilar artery.", + "Endovascular treatment was recommended and performed on this patient.", + "Antegrade endovascular recanalization of the left VA origin occlusion failed because the micro guidewire was unable to traverse the occluded segment.", + "Robust collateral from the deep cervical artery to the V3 segment of the left VA developed.", + "The micro guidewire was advanced to the V3 segment of the left VA.", + "The micro guidewire was reversely passed through the occluded segment.", + "The occlusion and stenosis of the left VA were successfully resolved with angioplasty and stenting.", + "After the procedure, the patient reported no neurological symptoms under medical therapy during 3-month follow-up." + ] + }, + { + "id": "multiclinsum_test_2369_en.txt", + "fulltext": "A 29-year-old primigravida Caucasian female with a past medical history significant for short stature, tobacco use, and poorly controlled pregestational type 2 diabetes mellitus (DM) presented to clinic for routine antenatal care. She was first diagnosed with diabetes mellitus at age 22 and managed with metformin prior to pregnancy with a history of poor glycemic control. She was transitioned to glyburide 5 mg twice daily by her obstetrician and subsequently increased to 10 mg twice daily secondary to continued elevated blood glucose levels (fasting ranged from 78 to 113 mg/dl and 2-hour post prandial ranged from 97 to 332 mg/dl). At 13 and 3/7 weeks of pregnancy, the patient was admitted for tighter blood glucose management, initiation of insulin, and a dietician consult to achieve improved control of glucose levels. A baseline hemoglobin A1c was obtained on admission and noted to be high at 8%. Previous maternal hemoglobin A1c levels were not reported. Antenatal fetal ultrasound at 22 weeks was notable for severe sacral agenesis, bilateral renal pelvis dilatation, single umbilical artery, and findings suggestive of pulmonary hypoplasia. The patient was referred to a tertiary care fetal and neonatal medicine center in the USA for further evaluation, and fetal magnetic resonance imaging (MRI) was recommended for confirmatory testing. Fetal MRI at 29 weeks gestation showed absence of the lower two-thirds of the spine with corresponding spinal cord abnormality compatible with type 1 caudal regression syndrome with noted horseshoe kidneys . No fetal cardiac anomaly was detected. Fetal anomalies were likely secondary to poorly controlled diabetes during early pregnancy. There was no significant family history.\nThe mother was counseled extensively by maternal fetal medicine and neonatology that the infant’s prognosis was extremely guarded given the severe spinal cord anomaly and possible pulmonary hypoplasia with substantial risk of intrauterine fetal demise (IUFD), perinatal death, or paraplegia/quadriplegia in a surviving infant. The mother was offered additional confirmatory genetic testing, which she declined. After extensive counseling and discussion of options, which included termination of pregnancy, early induction of labor for provision of comfort care, or continuation of pregnancy to term, the mother opted to continue the pregnancy. She chose to pursue a plan for induction of labor at term (~ 39 weeks) with goal of respiratory resuscitation of the infant and admission to the neonatal intensive care unit (NICU) for stabilization if the infant was viable. She was followed closely throughout the remainder of her pregnancy by maternal–fetal medicine (MFM) and the fetal neonatal medicine center. She continued to return for regular obstetric care for the next 10 weeks with close attention to fetal growth and glucose control. On return obstetric follow up at 37 weeks gestation, the patient’s glucose log showed improved glycemic control with fasting glucose levels < 90 mg/dL and 2-hour postprandial values typically < 120 mg/dL. She was seen by her obstetrician at 39 and 0/7 weeks, at which time there was normal fetal movement and offered induction of labor. She chose to schedule an induction of labor at 39 and 3/7 weeks. Unfortunately, when she presented to labor and delivery for her scheduled induction, antenatal ultrasound showed low amniotic fluid index (AFI) and absent fetal heart tones consistent with intrauterine fetal demise. Labor was medically induced with subsequent vaginal delivery of a stillborn male. Evaluation of the newborn demonstrated normal facies and upper extremities, with normal chest to 2 cm below nipple line and bony spine palpable to approximately the lower two-thirds. No further bony spine was palpable. Feet and legs were present but very small, as was the abdomen, and a left club foot deformity was noted. The baby was small for gestational age with a birth weight of 2070 g, which is less than the first percentile with a Z score of − 3.3 according to the Fenton growth chart. Postnatal cytogenetics confirmed a normal male 46 XY karyotype.\nThe family declined autopsy, so a minimally invasive autopsy was performed. Postmortem MRI confirmed findings of severe caudal agenesis and abrupt cord termination . Several skeletal abnormalities were visualized on the corresponding CT autopsy . The infant was in a frog-like position with flexion and abduction at the hips and flexion at the knees. Bilateral iliac wings were hypoplastic and closely approximated at midline secondary to sacral agenesis. Other deformities included a single umbilical artery, horseshoe kidneys , a left talipes equinovarus deformity, and eight bilateral thoracic ribs .", + "fulltext_subclaims": [ + "The patient is a 29-year-old primigravida Caucasian female.", + "She has a past medical history significant for short stature.", + "She has a past medical history significant for tobacco use.", + "She has a past medical history significant for poorly controlled pregestational type 2 diabetes mellitus.", + "She was first diagnosed with diabetes mellitus at age 22.", + "She was managed with metformin prior to pregnancy.", + "She was transitioned to glyburide 5 mg twice daily by her obstetrician.", + "She was subsequently increased to 10 mg twice daily.", + "Her fasting blood glucose levels ranged from 78 to 113 mg/dl.", + "Her 2-hour post prandial blood glucose levels ranged from 97 to 332 mg/dl.", + "At 13 and 3/7 weeks of pregnancy, she was admitted for tighter blood glucose management.", + "At 13 and 3/7 weeks of pregnancy, insulin was initiated.", + "A dietician consult was obtained.", + "A baseline hemoglobin A1c was obtained on admission.", + "The baseline hemoglobin A1c was noted to be high at 8%.", + "Previous maternal hemoglobin A1c levels were not reported.", + "An antenatal fetal ultrasound at 22 weeks was notable for severe sacral agenesis.", + "An antenatal fetal ultrasound at 22 weeks was notable for bilateral renal pelvis dilatation.", + "An antenatal fetal ultrasound at 22 weeks was notable for a single umbilical artery.", + "An antenatal fetal ultrasound at 22 weeks was notable for findings suggestive of pulmonary hypoplasia.", + "The patient was referred to a tertiary care fetal and neonatal medicine center in the USA.", + "Fetal magnetic resonance imaging (MRI) was recommended.", + "Fetal MRI at 29 weeks gestation showed absence of the lower two-thirds of the spine.", + "Fetal MRI at 29 weeks gestation showed a corresponding spinal cord abnormality compatible with type 1 caudal regression syndrome.", + "Fetal MRI at 29 weeks gestation showed noted horseshoe kidneys.", + "No fetal cardiac anomaly was detected.", + "Fetal anomalies were likely secondary to poorly controlled diabetes during early pregnancy.", + "There was no significant family history.", + "The mother was counseled extensively by maternal fetal medicine and neonatology.", + "The infant’s prognosis was extremely guarded.", + "The mother was offered additional confirmatory genetic testing.", + "The mother declined additional confirmatory genetic testing.", + "The mother opted to continue the pregnancy.", + "The mother chose to pursue a plan for induction of labor at term (~ 39 weeks).", + "The mother chose to pursue a plan for respiratory resuscitation of the infant.", + "The mother chose to pursue a plan for admission to the neonatal intensive care unit (NICU) for stabilization.", + "She was followed closely throughout the remainder of her pregnancy.", + "She continued to return for regular obstetric care.", + "On return obstetric follow up at 37 weeks gestation, the patient’s glucose log showed improved glycemic control.", + "On return obstetric follow up at 37 weeks gestation, fasting glucose levels were < 90 mg/dL.", + "On return obstetric follow up at 37 weeks gestation, 2-hour postprandial values were typically < 120 mg/dL.", + "She was seen by her obstetrician at 39 and 0/7 weeks.", + "There was normal fetal movement at 39 and 0/7 weeks.", + "She was offered induction of labor at 39 and 0/7 weeks.", + "She chose to schedule an induction of labor at 39 and 3/7 weeks.", + "When she presented to labor and delivery for her scheduled induction, antenatal ultrasound showed low amniotic fluid index.", + "When she presented to labor and delivery for her scheduled induction, antenatal ultrasound showed absent fetal heart tones.", + "The diagnosis was intrauterine fetal demise.", + "Labor was medically induced.", + "A vaginal delivery of a stillborn male occurred.", + "Evaluation of the newborn demonstrated normal facies.", + "Evaluation of the newborn demonstrated normal upper extremities.", + "Evaluation of the newborn demonstrated a normal chest to 2 cm below the nipple line.", + "Evaluation of the newborn demonstrated a bony spine palpable to approximately the lower two-thirds.", + "No further bony spine was palpable.", + "Feet and legs were present but very small.", + "A left club foot deformity was noted.", + "The baby was small for gestational age.", + "The birth weight was 2070 g.", + "The birth weight was less than the first percentile.", + "The Z score was −3.3 according to the Fenton growth chart.", + "Postnatal cytogenetics confirmed a normal male 46 XY karyotype.", + "The family declined autopsy.", + "A minimally invasive autopsy was performed.", + "Postmortem MRI confirmed findings of severe caudal agenesis.", + "Postmortem MRI confirmed abrupt cord termination.", + "Several skeletal abnormalities were visualized on the corresponding CT autopsy.", + "The infant was in a frog-like position.", + "Flexion and abduction at the hips were noted.", + "Flexion at the knees was noted.", + "Bilateral iliac wings were hypoplastic.", + "Bilateral iliac wings were closely approximated at midline.", + "A single umbilical artery was noted.", + "Horseshoe kidneys were noted.", + "A left talipes equinovarus deformity was noted.", + "Eight bilateral thoracic ribs were noted." + ], + "summary": "This case of type 1 caudal regression syndrome in the setting of maternal pregestational diabetes mellitus resulted in stillbirth. The mother was a 29-year-old Caucasian primigravida female with past medical history of poorly controlled type 2 diabetes managed with metformin prior to pregnancy, prompting admission for glucose management and initiation of insulin at 13 weeks. Baseline hemoglobin A1c was high at 8.0%. Fetal ultrasound at 22 weeks was notable for severe sacral agenesis, bilateral renal pelvis dilatation, single umbilical artery, and pulmonary hypoplasia. Fetal magnetic resonance imaging at 29 weeks showed absent lower two-thirds of the spine with corresponding spinal cord abnormality compatible with type 1 caudal regression syndrome. The mother delivered a male stillborn at 39 and 3/7 weeks. Minimally invasive postmortem magnetic resonance imaging and computed tomography autopsy were performed to confirm clinical findings when family declined conventional autopsy. Etiology of sacral agenesis was attributed to poorly controlled maternal diabetes early in gestation.", + "summary_subclaims": [ + "This case involved type 1 caudal regression syndrome.", + "The case occurred in the setting of maternal pregestational diabetes mellitus.", + "The case resulted in stillbirth.", + "The mother was a 29-year-old Caucasian primigravida female.", + "The mother had a past medical history of poorly controlled type 2 diabetes.", + "The mother was managed with metformin prior to pregnancy.", + "The mother was admitted for glucose management and initiation of insulin at 13 weeks.", + "Baseline hemoglobin A1c was 8.0%.", + "Fetal ultrasound at 22 weeks showed severe sacral agenesis.", + "Fetal ultrasound at 22 weeks showed bilateral renal pelvis dilatation.", + "Fetal ultrasound at 22 weeks showed a single umbilical artery.", + "Fetal ultrasound at 22 weeks showed pulmonary hypoplasia.", + "Fetal MRI at 29 weeks showed absent lower two-thirds of the spine.", + "Fetal MRI at 29 weeks showed a spinal cord abnormality compatible with type 1 caudal regression syndrome.", + "The mother delivered a male stillborn at 39 and 3/7 weeks.", + "Minimally invasive postmortem MRI and CT autopsy were performed.", + "The family declined conventional autopsy.", + "The etiology of sacral agenesis was attributed to poorly controlled maternal diabetes early in gestation." + ] + }, + { + "id": "multiclinsum_test_366_en.txt", + "fulltext": "A 45-year-old male patient presented to the OPD with complaints of pain in the left hip and difficulty in walking for 4 years. The patient had a history of fever and swelling over the left hip in childhood with no treatment taken for the same. The patient had no history of tuberculosis, weight loss, anorexia, morning stiffness, other joints involvement, or any history of drug abuse. The patient was not a known case of asthma, diabetes, and hypertension. The patient had no history of chronic alcohol consumption or tobacco smoking. Local examination revealed tenderness in the Scarpa’s triangle and over the greater trochanter. The movements at the hip were restricted in all planes with the presence of 1 cm of true shortening of the limb as compared to the opposite side with adduction deformity.\nThe patient was investigated radiographically with X-ray of the pelvis with both hips which was suggestive of osteoarthritis of the left hip with narrow femoral canal (Grade I Dorr), collapse of femoral head, narrow and broad neck of femur, and arthritic changes in acetabulum.\nThe patient was initially managed with traction to cause relaxation of the contracted soft tissues. The patient was also started with physiotherapy to increase the strength in the affected muscles around the hip. As the patient’s X-ray showed hip with narrow femoral canal (champagne flute canal) , templating for the hip was done and surgery was planned as total hip arthroplasty using a Wagner cone stem for the femoral component. After obtaining fitness for surgery with ESR and CRP in normal range, the patient was operated in lateral position through posterior approach. The soft-tissue dissection and the dislocation of femoral head posed difficulty due to presence of soft-tissue contracture and fibrous tissue surrounding the hip joint. After acetabulum preparation, femoral canal preparation was done using small rasps and broaches and completed with no complications.\nUncemented total hip arthroplasty was done using Zimmer implant of acetabulum (Mallory head acetabulum shell 46 mm) with two self-tapping bone screws of size 6.5 mm, femoral component (uncemented Wagner cone prosthesis, 135°, size 16 with ceramic femoral head size of 28), and polyethylene liner of size 22. After implant placement, the movements at the hip joint in all planes were assessed and limb length compared for no discrepancy. Wound was closed in layers and the patient was given abduction bar to prevent dislocation postoperatively.\nPost-operative X-ray showed well-fixed femoral and acetabular components with proper inclination.\nThe patient was gradually initiated with hip range of motion exercises and weight-bearing with walker started after pain relief. At present 1.5 years follow-up, the patient is comfortable with no pain and difficulty in walking. The patient has good hip range of motion. The functional outcome is good as per Harris hip score. X-ray shows bony ingrowth at the tip of femoral stem and acetabulum without loosening of implants . Shorter follow-up period is the limitation of this case report.", + "fulltext_subclaims": [ + "The patient is a 45-year-old male.", + "The patient had pain in the left hip and difficulty in walking for 4 years.", + "The patient had a history of fever and swelling over the left hip in childhood.", + "The patient had no treatment for the childhood fever and swelling.", + "The patient had no history of tuberculosis.", + "The patient had no history of weight loss.", + "The patient had no history of anorexia.", + "The patient had no history of morning stiffness.", + "The patient had no history of other joints involvement.", + "The patient had no history of drug abuse.", + "The patient was not a known case of asthma.", + "The patient was not a known case of diabetes.", + "The patient was not a known case of hypertension.", + "The patient had no history of chronic alcohol consumption.", + "The patient had no history of tobacco smoking.", + "Local examination revealed tenderness in the Scarpa’s triangle.", + "Local examination revealed tenderness over the greater trochanter.", + "Movements at the hip were restricted in all planes.", + "There was 1 cm of true shortening of the limb as compared to the opposite side.", + "There was adduction deformity.", + "X-ray of the pelvis with both hips was suggestive of osteoarthritis of the left hip.", + "X-ray showed narrow femoral canal (Grade I Dorr).", + "X-ray showed collapse of femoral head.", + "X-ray showed narrow and broad neck of femur.", + "X-ray showed arthritic changes in acetabulum.", + "The patient was initially managed with traction.", + "The patient was started with physiotherapy.", + "Surgery was planned as total hip arthroplasty.", + "Templating for the hip was done.", + "The planned femoral component was a Wagner cone stem.", + "The patient was operated in lateral position.", + "The posterior approach was used.", + "Soft-tissue dissection posed difficulty.", + "Fibrous tissue surrounded the hip joint.", + "Femoral canal preparation was done using small rasps and broaches.", + "Femoral canal preparation was completed with no complications.", + "Uncemented total hip arthroplasty was done.", + "The acetabular component was a Zimmer implant of Mallory head acetabulum shell 46 mm.", + "Two self-tapping bone screws of size 6.5 mm were used.", + "The femoral component was an uncemented Wagner cone prosthesis, 135°, size 16.", + "The ceramic femoral head size was 28.", + "The polyethylene liner size was 22.", + "The wound was closed in layers.", + "The patient was given an abduction bar postoperatively.", + "Post-operative X-ray showed well-fixed femoral and acetabular components.", + "Post-operative X-ray showed proper inclination.", + "Hip range of motion exercises were gradually initiated.", + "Weight-bearing with walker was started after pain relief.", + "At 1.5 years follow-up, the patient is comfortable with no pain.", + "At 1.5 years follow-up, the patient has no difficulty in walking.", + "The patient has good hip range of motion.", + "The functional outcome is good as per Harris hip score.", + "X-ray shows bony ingrowth at the tip of femoral stem.", + "X-ray shows bony ingrowth at the acetabulum.", + "X-ray shows no loosening of implants.", + "Shorter follow-up period is the limitation of this case report." + ], + "summary": "A 45-year- old male patient presented to the OPD with complaints of pain in the left hip and difficulty in walking since for 4 years. The patient had a history of fever and swelling over the left hip in childhood with no treatment taken for the same. X-ray of pelvis with both hips showed deformed femoral head, short neck, narrow femoral canal (Grade 1 Dorr), and arthritic changes in acetabulum. We managed with total hip replacement using Wagner cone stem. Postoperatively, the patient is having good range of motion and having no difficulty in walking and weight- bearing. Functional outcome is good as per Harris hip score.", + "summary_subclaims": [ + "The patient is a 45-year-old male.", + "The patient had pain in the left hip.", + "The patient had difficulty in walking.", + "The symptoms had been present for 4 years.", + "The patient had a history of fever and swelling over the left hip in childhood.", + "The patient had no treatment for the childhood fever and swelling.", + "X-ray of pelvis with both hips showed deformed femoral head.", + "X-ray showed short neck.", + "X-ray showed narrow femoral canal (Grade 1 Dorr).", + "X-ray showed arthritic changes in acetabulum.", + "The patient was managed with total hip replacement using Wagner cone stem.", + "Postoperatively, the patient has good range of motion.", + "The patient has no difficulty in walking postoperatively.", + "The patient has no difficulty in weight-bearing postoperatively.", + "Functional outcome is good as per Harris hip score." + ] + }, + { + "id": "multiclinsum_test_3035_en.txt", + "fulltext": "A 29-year-old African American male individual presented to the emergency department (ED) for right upper quadrant abdominal pain and early satiety. Physical examination was unrevealing except for abdominal tenderness. His past medical history included 5 years of daily alcohol use and occasional marijuana use. A computed tomography (CT) scan revealed hepatomegaly with a large mass centered in the left lobe measuring 14 cm. Laboratory values showed mildly elevated transaminases, with an alanine transaminase (ALT) of 51, aspartate aminotransferase (AST) of 74, and an alkaline phosphatase of 93 units/L. The patient was then discharged with a planned outpatient hepatology follow-up.\n\nA total of 1 month later, the patient presented again to the ED with the same symptoms; magnetic resonance imaging (MRI) revealed a 19 cm enhancing left hepatic mass. Laboratory tests demonstrated a mild elevation in transaminases, a negative hepatitis viral panel, and unremarkable tumor marker levels, including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA19.9). After appropriate pain control, the patient was discharged again with plans for outpatient follow-up.\n\nThe patient was lost to follow-up owing to insurance concerns, until he presented to a different ED the following month for abdominal pain, vomiting, early satiety, and unintentional 10 lb weight loss. Abdominal CT angiography with contrast showed a 21 cm hepatic mass centered in the left hepatic lobe, and given the concern for hepatocellular carcinoma, the patient was admitted for biopsy and staging imaging. Laboratory tests revealed alkaline phosphatase elevation (451 IU/L) and mildly elevated transaminases, with an AST level of 93 units/L and an ALT of 45 units/L. His tumor marker laboratory results were within normal ranges (CA 19.9 < 14.0; AFP: 1.97; and CEA: 5.28). A chest CT revealed innumerable bilateral pulmonary nodules measuring up to 8 mm, favoring metastases. Initial histopathological examination of the liver biopsy specimens revealed a well-differentiated carcinoma characterized by a distinctive myxoid stroma with tubular and cribriform structures, consistent with metastatic adenoid cystic carcinoma. The patient underwent transcatheter arterial chemoembolization (TACE) and was discharged with a hematology–oncology follow-up.\n\nHe was readmitted 2 weeks later for a planned repeat TACE procedure, as well as a repeat liver biopsy for further testing. Initial laboratory values on admission were an AST of 44 units/L, ALT of 24 units/L, and alkaline phosphatase of 282 units/L. During this admission, a computed tomography (CT) scan of the neck soft tissue with contrast revealed a complex bilobed mass in the right parotid gland measuring approximately 6.5 cm. Its progression into the parapharyngeal space caused notable deformity of the oropharynx, raising further concerns about potential malignancy. A biopsy was taken with immunohistochemistry findings suggestive of ACC; however, BCAC could not be completely excluded without examination of a completely removed salivary gland tumor. Therefore, a presumptive diagnosis of stage IV adenoid cystic carcinoma with metastases to the liver and lung was made. Given the tremendous tumor burden and poor prognosis, the treatment goals were palliative, and the patient was started on a chemotherapeutic regimen with cisplatin and vinorelbine.\n\nA total of 5 months later, the patient presented to the emergency department with neurological symptoms, including lightheadedness and left-sided weakness. A CT scan revealed new right frontal hyperdensities, consistent with brain metastasis. During this admission, he received one dose of radiotherapy with a plan to finish five doses. He was then discharged with a planned outpatient follow-up.", + "fulltext_subclaims": [ + "The patient is a 29-year-old African American male.", + "He presented to the emergency department for right upper quadrant abdominal pain and early satiety.", + "Physical examination was unrevealing except for abdominal tenderness.", + "His past medical history included 5 years of daily alcohol use.", + "A CT scan revealed hepatomegaly with a large mass centered in the left lobe measuring 14 cm.", + "Laboratory values showed an ALT of 51 units/L.", + "The patient was discharged with a planned outpatient hepatology follow-up.", + "One month later, the patient presented again to the ED with the same symptoms.", + "MRI revealed a 19 cm enhancing left hepatic mass.", + "The patient was discharged again with plans for outpatient follow-up.", + "The patient was lost to follow-up owing to insurance concerns.", + "He presented to a different ED the following month for abdominal pain, vomiting, early satiety, and unintentional 10 lb weight loss.", + "Abdominal CT angiography with contrast showed a 21 cm hepatic mass centered in the left hepatic lobe.", + "The patient was admitted for biopsy and staging imaging.", + "A chest CT revealed innumerable bilateral pulmonary nodules measuring up to 8 mm, favoring metastases.", + "Initial histopathological examination of the liver biopsy specimens revealed a well-differentiated carcinoma characterized by a distinctive myxoid stroma with tubular and cribriform structures.", + "The histopathological findings were consistent with metastatic adenoid cystic carcinoma.", + "The patient underwent transcatheter arterial chemoembolization (TACE).", + "He was discharged with a hematology–oncology follow-up.", + "He was readmitted 2 weeks later for a planned repeat TACE procedure.", + "A CT scan of the neck soft tissue with contrast revealed a complex bilobed mass in the right parotid gland measuring approximately 6.5 cm.", + "The mass progressed into the parapharyngeal space, causing notable deformity of the oropharynx.", + "A biopsy was taken with immunohistochemistry findings suggestive of ACC.", + "A presumptive diagnosis of stage IV adenoid cystic carcinoma with metastases to the liver and lung was made.", + "The treatment goals were palliative.", + "The patient was started on a chemotherapeutic regimen with cisplatin and vinorelbine.", + "Five months later, the patient presented to the emergency department with neurological symptoms, including lightheadedness and left-sided weakness.", + "A CT scan revealed new right frontal hyperdensities, consistent with brain metastasis.", + "He received one dose of radiotherapy with a plan to finish five doses.", + "He was discharged with a planned outpatient follow-up." + ], + "summary": "We report the case of a 29-year-old African American male patient with a metastatic salivary gland tumor who presented initially with a large hepatic mass. He complained of right upper quadrant pain and early satiety. Abdominal computed tomography revealed hepatomegaly with a large mass centered in the left lobe measuring 14 cm. A computed tomography scan revealed innumerable bilateral pulmonary nodules measuring up to 8 mm, favoring metastases. Initial histopathological examination of the liver biopsy specimens revealed a well-differentiated carcinoma characterized by a distinctive myxoid stroma, consistent with metastatic adenoid cystic carcinoma. The patient underwent transcatheter arterial chemoembolization and was discharged with a hematology-oncology follow-up. A presumptive diagnosis of stage IV adenoid cystic carcinoma with lung and liver metastases was made. The patient was given cisplatin and vinorelbine.", + "summary_subclaims": [ + "The patient is a 29-year-old African American male.", + "The patient has a metastatic salivary gland tumor.", + "The patient presented with a large hepatic mass.", + "The patient complained of right upper quadrant pain.", + "The patient complained of early satiety.", + "Abdominal computed tomography revealed hepatomegaly.", + "The liver mass measured 14 cm.", + "The liver mass was centered in the left lobe.", + "Computed tomography revealed innumerable bilateral pulmonary nodules.", + "The pulmonary nodules measured up to 8 mm.", + "The pulmonary nodules favored metastases.", + "Initial histopathological examination of liver biopsy specimens revealed a well-differentiated carcinoma.", + "The histopathological examination showed a distinctive myxoid stroma.", + "The histopathological findings were consistent with metastatic adenoid cystic carcinoma.", + "The patient underwent transcatheter arterial chemoembolization.", + "The patient was discharged with hematology-oncology follow-up.", + "A presumptive diagnosis of stage IV adenoid cystic carcinoma was made.", + "The diagnosis included lung and liver metastases.", + "The patient was given cisplatin.", + "The patient was given vinorelbine." + ] + }, + { + "id": "multiclinsum_test_1218_en.txt", + "fulltext": "A 53-year-old man (85 kg and 170 cm) was admitted for rupture of spleen caused by an accidental fall.\nEmergency splenectomy was planned under general anesthesia. Preoperative emergency ultrasound examination including the heart, chest, and abdomen were performed, and it was found that spleen had been ruptured and was accompanied by active bleeding, complicated with progressive hemochrome reduction, which was the main reason for the patient to undergo emergency surgery. Preoperative ultrasound showed no heart or chest abnormalities. The patient did not complain of dyspnea preoperatively, and preoperative CT showed no hemothorax or pneumothorax . Initial vital signs before anesthesia were a blood pressure of 126/82 mm Hg, heart rate of 75 bpm, and an oxygen partial pressure (SpO2) of 95% while inhaling air. Anesthesia was induced with sufentanil 0.3 µg/kg, rocuronium 0.1 mg/kg, and propofol 3 mg/kg. Tracheal intubation was successfully performed with video laryngoscopy, and positive pressure ventilation was performed with an airway peak pressure of 14 cm H2O. Because the patient's thick chest wall, breath sounds were difficult to auscultate. About 2 min after tracheal intubation, it was difficult to ventilate. The airway peak pressure increased progressively, reaching a maximum of 50 cm H2O and SpO2 dropped, reaching a minimum of 70%. Because of obesity and the thick chest wall, the cause of respiratory failure could not be determined by traditional auscultation. Following the BLUE protocol, a recommended area of the chest was scanned by bedside ultrasound. The pleural slide sign disappeared in the upper and lower blue points of the left lung, and in M-mode, an obvious parallel line sign could be seen below the pleura. The boundary of pneumothorax (lung points) was rapidly confirmed by ultrasound. To avoid lung injury and secondary pneumothorax, a closed thoracic drainage tube was placed in the area guided by ultrasound. The interval from suspicion of pneumothorax to placement of the drainage tube was less than 3 min. After many bubbles had emerged from the water seal bottle, the airway pressure dropped to 20 cm H2O and the SpO2 returned to 96%-100%. After the patient's vital signs stabilized, the splenectomy continued and was successfully completed. The patient was sent to the intensive care unit (ICU) with a endotracheal tube for further treatment after surgery. On day 1 after surgery, the endotracheal tube was removed. On day 6, the closed thoracic drainage tube was removed. On day 9, the patient was discharged from the hospital without any complications.\nAnemia (hemoglobin 85 g/L).\nFocused assessment with sonography in trauma (FAST) has been extensively utilized and studied in blunt and penetrating trauma. Following the FAST protocol, organ damage can be rapidly evaluated by the amount of free fluid in the chest, abdominal, and pelvic cavities. In this case, preoperative emergency ultrasound examination of the heart, chest and abdomen found that spleen had been ruptured and active bleeding was complicated by progressive hemochrome reduction, which was also the main reason for the patient to undergo emergency surgery. Preoperative ultrasound showed no abnormalities in the heart or chest. Following the BLUE protocol, LUS confirmed that the pleural slide sign had disappeared in the recommended area of the left lung, and in M-mode, an obvious parallel line sign was seen below the pleura . The boundary of the pneumothorax (lung points) was rapidly confirmed by ultrasound .", + "fulltext_subclaims": [ + "A 53-year-old man was admitted for rupture of spleen caused by an accidental fall.", + "Emergency splenectomy was planned under general anesthesia.", + "Preoperative emergency ultrasound examination including the heart, chest, and abdomen were performed.", + "Preoperative ultrasound showed no heart or chest abnormalities.", + "The patient did not complain of dyspnea preoperatively.", + "Preoperative CT showed no hemothorax or pneumothorax.", + "Initial vital signs before anesthesia were a blood pressure of 126/82 mm Hg, heart rate of 75 bpm, and an oxygen partial pressure (SpO2) of 95% while inhaling air.", + "Anesthesia was induced with sufentanil 0.3 µg/kg, rocuronium 0.1 mg/kg, and propofol 3 mg/kg.", + "Tracheal intubation was successfully performed with video laryngoscopy.", + "Positive pressure ventilation was performed with an airway peak pressure of 14 cm H2O.", + "Because the patient's thick chest wall, breath sounds were difficult to auscultate.", + "About 2 min after tracheal intubation, it was difficult to ventilate.", + "The airway peak pressure increased progressively, reaching a maximum of 50 cm H2O.", + "SpO2 dropped, reaching a minimum of 70%.", + "Following the BLUE protocol, a recommended area of the chest was scanned by bedside ultrasound.", + "The pleural slide sign disappeared in the upper and lower blue points of the left lung.", + "In M-mode, an obvious parallel line sign could be seen below the pleura.", + "The boundary of pneumothorax (lung points) was rapidly confirmed by ultrasound.", + "A closed thoracic drainage tube was placed in the area guided by ultrasound.", + "The interval from suspicion of pneumothorax to placement of the drainage tube was less than 3 min.", + "After many bubbles had emerged from the water seal bottle, the airway pressure dropped to 20 cm H2O.", + "SpO2 returned to 96%-100%.", + "The patient was sent to the intensive care unit (ICU) with an endotracheal tube for further treatment after surgery.", + "On day 1 after surgery, the endotracheal tube was removed.", + "On day 6, the closed thoracic drainage tube was removed.", + "On day 9, the patient was discharged from the hospital without any complications.", + "Anemia (hemoglobin 85 g/L).", + "Focused assessment with sonography in trauma (FAST) has been extensively utilized and studied in blunt and penetrating trauma.", + "Following the FAST protocol, organ damage can be rapidly evaluated by the amount of free fluid in the chest, abdominal, and pelvic cavities.", + "In this case, preoperative emergency ultrasound examination of the heart, chest and abdomen found that spleen had been ruptured and active bleeding was complicated by progressive hemochrome reduction, which was also the main reason for the patient to undergo emergency surgery.", + "Following the BLUE protocol, LUS confirmed that the pleural slide sign had disappeared in the recommended area of the left lung.", + "In M-mode, an obvious parallel line sign was seen below the pleura." + ], + "summary": "The patient was a 53-year-old man admitted for rupture of the spleen caused by an accidental fall and emergency splenectomy was planned. Anesthesia was induced, and tracheal intubation was performed successfully with a video laryngoscope. About 2 min after tracheal intubation, the airway peak pressure increased to 50 cm H2O and the oxygen saturation dropped to 70%. According to the BLUE protocol, a recommended area of the chest was scanned by ultrasound. The pleural slide sign disappeared and obvious parallel line sign could be seen in the left lung. The boundary of pneumothorax (lung points) were rapidly confirmed by ultrasound. To avoid lung injury, a closed thoracic drainage tube was placed in the involved area. On day 9 after surgery, the patient was discharged from the hospital without any complications.", + "summary_subclaims": [ + "The patient was a 53-year-old man.", + "The patient was admitted for rupture of the spleen caused by an accidental fall.", + "Emergency splenectomy was planned.", + "Anesthesia was induced.", + "Tracheal intubation was performed successfully with a video laryngoscope.", + "About 2 min after tracheal intubation, the airway peak pressure increased to 50 cm H2O.", + "The oxygen saturation dropped to 70%.", + "According to the BLUE protocol, a recommended area of the chest was scanned by ultrasound.", + "The pleural slide sign disappeared.", + "An obvious parallel line sign could be seen in the left lung.", + "The boundary of pneumothorax (lung points) were rapidly confirmed by ultrasound.", + "A closed thoracic drainage tube was placed in the involved area.", + "The patient was discharged from the hospital on day 9 after surgery.", + "The patient was discharged without any complications." + ] + }, + { + "id": "multiclinsum_test_2383_en.txt", + "fulltext": "A 71-year-old Japanese woman underwent a living-donor liver transplant for hepatocellular carcinoma 18 years prior to her inclusion in this case study. She was receiving TAC orally at 2 mg/day (twice daily), with a trough blood concentration of approximately 4 ng/mL and stable trough blood concentration/dose (C/D) ratio (ng/mL/mg) of approximately 2. The patient presented night sweats, anorexia, and swelling on the left side of the neck. Owing to the presence of atypical cells in her peripheral blood and a substantial decrease in her platelet count (20,000/µL), she was urgently referred to our hospital for admission, thorough examination, and treatment. The patient was diagnosed with post-transplant lymphoproliferative disease (histological type: Burkitt's lymphoma) after admission. She was managed in the intensive care unit with continuous hemodiafiltration (CHDF) and positive airway pressure (CPAP) for 2 weeks because of tumor collapse syndrome, left subdural hematoma, and acute kidney injury (AKI). Figure illustrates the course of this case. Upon admission, the patient presented with elevated lactate dehydrogenase (LDH; 11,232 U/L) and alanine aminotransferase (ALT; 164 U/L) levels, indicating potential liver dysfunction. Consequently, the TAC dose was reduced from 2 to 1 mg/day. Furthermore, owing to the presence of AKI, TAC administration was temporarily discontinued. As oxygenation improved and the patient's condition progressed, cyclophosphamide–prednisolone (CP) therapy was initiated. Following CP therapy, the LDH and ALT levels decreased. Subsequently, TAC administration was resumed at 2 mg/day. The patient received two cycles of R-HyperCVAD (rituximab, cyclophosphamide, doxorubicin, vincristine, and DEX) and R-MA (rituximab, methotrexate, cytarabine, and methylprednisolone) alternating therapy. DEX (33 mg/day) was administered intravenously on days 1–4 and days 11–14 of the R-HyperCVAD course. Additionally, aprepitant (APR) was administered on days 1–5 in both courses. The TAC dosage was adjusted to maintain a trough blood concentration of approximately 2 ng/mL. Fluconazole 200 mg/day was administered orally throughout the TAC-administration period.\nThe C/D ratio of TAC during the first course of R-HyperCVAD was initially low (1.07) on day 11, but then increased, reaching 2.57 on day 25. Similarly, during the second course of R-HyperCVAD, the C/D ratio on day 3 (in Fig. , day 57) was 2.42, but subsequently decreased to 0.92 on day 11. However, it then exhibited an upward trend, reaching 1.8 on day 18 and 2.86 on day 32. The C/D ratio of TAC on day 4 (in Fig. , day 93) of the second course of R-MA was 4.4, but decreased to 1.25 on day 11. Notably, the C/D ratio started to increase during DEX administration on days 11–14 of R-HyperCVAD treatment and did not decrease after 2 weeks, whereas it exhibited a decreasing trend during R-MA treatment. Therefore, the decrease in the C/D ratio was primarily attributed to APR rather than to DEX.", + "fulltext_subclaims": [ + "The patient was a 71-year-old Japanese woman.", + "She underwent a living-donor liver transplant for hepatocellular carcinoma 18 years prior to her inclusion in this case study.", + "She was receiving TAC orally at 2 mg/day (twice daily).", + "The trough blood concentration of TAC was approximately 4 ng/mL.", + "The trough blood concentration/dose (C/D) ratio of TAC was approximately 2.", + "The patient presented with night sweats, anorexia, and swelling on the left side of the neck.", + "Atypical cells were present in her peripheral blood.", + "Her platelet count was 20,000/µL.", + "She was urgently referred to the hospital for admission, thorough examination, and treatment.", + "She was diagnosed with post-transplant lymphoproliferative disease (histological type: Burkitt's lymphoma) after admission.", + "She was managed in the intensive care unit with continuous hemodiafiltration and CPAP for 2 weeks.", + "She had tumor collapse syndrome.", + "She had a left subdural hematoma.", + "She had acute kidney injury.", + "Upon admission, her lactate dehydrogenase (LDH) level was 11,232 U/L.", + "Upon admission, her alanine aminotransferase (ALT) level was 164 U/L.", + "The TAC dose was reduced from 2 to 1 mg/day.", + "TAC administration was temporarily discontinued owing to the presence of AKI.", + "Cyclophosphamide–prednisolone (CP) therapy was initiated.", + "Following CP therapy, the LDH and ALT levels decreased.", + "TAC administration was resumed at 2 mg/day.", + "The patient received two cycles of R-HyperCVAD and R-MA alternating therapy.", + "DEX (33 mg/day) was administered intravenously on days 1–4 and days 11–14 of the R-HyperCVAD course.", + "Aprepitant (APR) was administered on days 1–5 in both courses.", + "The TAC dosage was adjusted to maintain a trough blood concentration of approximately 2 ng/mL.", + "Fluconazole 200 mg/day was administered orally throughout the TAC-administration period.", + "The C/D ratio of TAC during the first course of R-HyperCVAD was initially low (1.07) on day 11.", + "The C/D ratio of TAC during the first course of R-HyperCVAD increased to 2.57 on day 25.", + "During the second course of R-HyperCVAD, the C/D ratio on day 3 was 2.42.", + "During the second course of R-HyperCVAD, the C/D ratio decreased to 0.92 on day 11.", + "The C/D ratio of TAC during the second course of R-HyperCVAD increased to 1.8 on day 18.", + "The C/D ratio of TAC during the second course of R-HyperCVAD increased to 2.86 on day 32.", + "The C/D ratio of TAC on day 4 of the second course of R-MA was 4.4.", + "The C/D ratio of TAC on day 11 of the second course of R-MA was 1.25.", + "The decrease in the C/D ratio was primarily attributed to APR rather than to DEX." + ], + "summary": "A 71-year-old woman underwent liver transplantation for hepatocellular carcinoma 18 years prior to her inclusion in this case study. She was receiving TAC orally at 2 mg/day and had a stable trough blood concentration of approximately 4 ng/mL and a trough blood concentration/dose (C/D) ratio of approximately 2. The patient was diagnosed with post-transplant lymphoproliferative disease (histological type: Burkitt's lymphoma) after admission. Thereafter, the patient received cyclophosphamide-prednisolone (CP), followed by two courses of R-HyperCVAD (rituximab, cyclophosphamide, doxorubicin, vincristine, and DEX) and R-MA (rituximab, methotrexate, and cytarabine) replacement therapy. DEX (33 mg/day) was administered intravenously on days 1-4 and days 11-14 of R-HyperCVAD treatment, and aprepitant (APR) was administered on days 1-5 in both courses. The TAC C/D ratio decreased to approximately 1 on day 11 during both courses, and then increased. Furthermore, a decreasing trend in the TAC C/D ratio was observed after R-MA therapy. The decrease in the TAC C/D ratio was attributed to APR administration rather than to DEX.", + "summary_subclaims": [ + "The patient was a 71-year-old woman.", + "She underwent liver transplantation for hepatocellular carcinoma 18 years prior to her inclusion in this case study.", + "She was receiving TAC orally at 2 mg/day.", + "She had a stable trough blood concentration of approximately 4 ng/mL.", + "She had a trough blood concentration/dose (C/D) ratio of approximately 2.", + "The patient was diagnosed with post-transplant lymphoproliferative disease.", + "The histological type of the post-transplant lymphoproliferative disease was Burkitt's lymphoma.", + "The patient received cyclophosphamide-prednisolone (CP).", + "The patient received two courses of R-HyperCVAD (rituximab, cyclophosphamide, doxorubicin, vincristine, and DEX).", + "The patient received R-MA (rituximab, methotrexate, and cytarabine) replacement therapy.", + "DEX (33 mg/day) was administered intravenously on days 1-4 and days 11-14 of R-HyperCVAD treatment.", + "Aprepitant (APR) was administered on days 1-5 in both courses.", + "The TAC C/D ratio decreased to approximately 1 on day 11 during both courses.", + "The TAC C/D ratio then increased.", + "A decreasing trend in the TAC C/D ratio was observed after R-MA therapy.", + "The decrease in the TAC C/D ratio was attributed to APR administration rather than to DEX." + ] + }, + { + "id": "multiclinsum_test_3259_en.txt", + "fulltext": "A 47-year-old male developed heart failure due to dilated cardiomyopathy 12 years ago. A cardiac resynchronization therapy-defibrillator (CRT-D; Medtronic® Viva XT CRT-D; AAI 60) was implanted due to VF 7 years ago, and as a bridge to transplantation, a HeartMate II® LVAD was implanted 4 years ago. No arrhythmia developed immediately after LVAD implantation; thus, his CRT-D shock therapy was turned off immediately after LVAD implantation. At the time of LVAD implantation, his transthoracic echocardiographic study showed a significant decrease in the left ventricular (LV) contractility (ejection fraction; 13%), dilation of left ventricle (51 mm in diastole) and trivial aortic regurgitation (AR) without opening of aortic valve but right ventricular (RV) contraction had maintained well relatively (RV fractional area change; 33%).\n\nEight months after LVAD implantation, the patient developed palpitations and was admitted to our hospital due to repeated VAs necessitating electrical defibrillation. Echocardiography showed the left ventricle diameter did not change, whereas right ventricle volume was slightly enlarged. The repeated VAs were also refractory to various anti-arrhythmic agents, including amiodarone, nifekalant, mexiletine and lidocain, with eventual progression to sustained VF. The hemodynamic compromise due to sustained VF resulted in liver congestion, which was alleviated with a phosphodiesterase type 5 inhibitor, diuretics, and rotation speed optimization (from 8800 to 9600 rpm). These interventions reduced organ dysfunction, suggesting that minimum-required perfusion to vital organs was maintained even under sustained VF. The patient was followed up on an outpatient basis thereafter.\n\nApproximately 2 years after the development of sustained VF, paroxysmal AF was detected on the monitoring records of CRT-D, with a gradually increasing frequency. After 3 years of sustained VF, the patient was readmitted to our hospital due to worsening of symptoms associated with right heart failure and liver congestion (total bilirubin, 3.9 mg/dl). Although his electrocardiogram remained sustained VF, the CRT-D revealed conversion of the sinus or atrial pacing rhythm to persistent AF. Transthoracic echocardiography revealed that fibrillation of the atrium resulted in the disappearance of not only the mitral flow but also the RV outflow tract doppler flow by the atrial kick. Under sustained VF, RV cardiac output is greatly dependent on atrial kick in which the contribution of atrial kick extraordinary enhanced. The hemodynamic study indicated that the pressure wave from the right atrium (RA) to the right ventricle was significantly flattened resulting that the pulmonary artery pulsatility index, which is defined as the ratio of pulmonary artery pulse pressure to right atrial pressure, was markedly decreased. It suggested a marked reduction in blood flow induced by RA contraction in persistent AF as opposed to sinus rhythm. As the incremental rotation speed lead to an increase in RA pressure (RAP) from 19 mmHg to 22 mmHg, the rotation speed was set to 9600 rpm and the right heart congestion was treated with additional diuretics insufficiently and the enhanced level of total bilirubin was prolonged. Until four months later, heart failure was gradually improved and the level of total bilirubin decreased below 2 mg/dl. The monitoring records of CRT-D revealed the recovery of sinus rhythm during previous four months. Although he had remained sustained VF, the recovery of sinus rhythm finely corresponded to the improvement of heart failure and the level of his total bilirubin decreased to 1.2 mg/dl. It intensely corroborated the contribution of persistent AF on the worsening of right heart failure.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "He developed heart failure due to dilated cardiomyopathy 12 years ago.", + "A cardiac resynchronization therapy-defibrillator (CRT-D; Medtronic® Viva XT CRT-D; AAI 60) was implanted due to VF 7 years ago.", + "A HeartMate II® LVAD was implanted 4 years ago.", + "No arrhythmia developed immediately after LVAD implantation.", + "His CRT-D shock therapy was turned off immediately after LVAD implantation.", + "At the time of LVAD implantation, his transthoracic echocardiographic study showed a significant decrease in the left ventricular (LV) contractility (ejection fraction; 13%).", + "The left ventricle was dilated (51 mm in diastole) at the time of LVAD implantation.", + "There was trivial aortic regurgitation (AR) without opening of aortic valve at the time of LVAD implantation.", + "The right ventricular (RV) fractional area change was 33% at the time of LVAD implantation.", + "Eight months after LVAD implantation, the patient developed palpitations.", + "He was admitted to our hospital due to repeated VAs necessitating electrical defibrillation.", + "Echocardiography showed the left ventricle diameter did not change.", + "The right ventricle volume was slightly enlarged.", + "The repeated VAs were refractory to various anti-arrhythmic agents, including amiodarone, nifekalant, mexiletine and lidocaine.", + "The VAs eventually progressed to sustained VF.", + "Hemodynamic compromise due to sustained VF resulted in liver congestion.", + "Liver congestion was alleviated with a phosphodiesterase type 5 inhibitor, diuretics, and rotation speed optimization (from 8800 to 9600 rpm).", + "These interventions reduced organ dysfunction.", + "The interventions suggested that minimum-required perfusion to vital organs was maintained even under sustained VF.", + "The patient was followed up on an outpatient basis thereafter.", + "Approximately 2 years after the development of sustained VF, paroxysmal AF was detected on the monitoring records of CRT-D.", + "The frequency of paroxysmal AF gradually increased.", + "After 3 years of sustained VF, the patient was readmitted to our hospital due to worsening of symptoms associated with right heart failure and liver congestion (total bilirubin, 3.9 mg/dl).", + "His electrocardiogram remained sustained VF.", + "The CRT-D revealed conversion of the sinus or atrial pacing rhythm to persistent AF.", + "Transthoracic echocardiography revealed that fibrillation of the atrium resulted in the disappearance of not only the mitral flow but also the RV outflow tract doppler flow by the atrial kick.", + "Under sustained VF, RV cardiac output is greatly dependent on atrial kick.", + "The contribution of atrial kick was extraordinarily enhanced.", + "The hemodynamic study indicated that the pressure wave from the right atrium (RA) to the right ventricle was significantly flattened.", + "The pulmonary artery pulsatility index was markedly decreased.", + "The pulmonary artery pulsatility index is defined as the ratio of pulmonary artery pulse pressure to right atrial pressure.", + "It suggested a marked reduction in blood flow induced by RA contraction in persistent AF as opposed to sinus rhythm.", + "The incremental rotation speed led to an increase in RA pressure (RAP) from 19 mmHg to 22 mmHg.", + "The rotation speed was set to 9600 rpm.", + "Right heart congestion was treated with additional diuretics insufficiently.", + "The enhanced level of total bilirubin was prolonged.", + "Until four months later, heart failure was gradually improved.", + "The level of total bilirubin decreased below 2 mg/dl.", + "The monitoring records of CRT-D revealed the recovery of sinus rhythm during previous four months.", + "Although he had remained sustained VF, the recovery of sinus rhythm finely corresponded to the improvement of heart failure.", + "The level of his total bilirubin decreased to 1.2 mg/dl.", + "It intensely corroborated the contribution of persistent AF on the worsening of right heart failure." + ], + "summary": "We describe the case of a patient under sustained ventricular fibrillation for extraordinarily long duration who was stabilized using LVAD support and in whom newly developed atrial fibrillation led to a significant worsening of right heart failure while using an LVAD.", + "summary_subclaims": [ + "The patient was under sustained ventricular fibrillation for extraordinarily long duration.", + "The patient was stabilized using LVAD support.", + "The patient developed atrial fibrillation.", + "The newly developed atrial fibrillation led to a significant worsening of right heart failure.", + "The worsening of right heart failure occurred while the patient was using an LVAD." + ] + }, + { + "id": "multiclinsum_test_1457_en.txt", + "fulltext": "A 31-year-old Egyptian male with American Society of Anesthesiologists (ASA) I physical status, with history of polytrauma since 1 week, had a left arm and right leg fracture. A complete trauma survey was done at the time of admission, with no other injury and acceptable laboratory and radiological investigations.The operation was done first to the fracture on left hand under general anesthesia with no complications. Then after 1 week, the patient was scheduled for an operation on the right leg. While sitting in the L3–L4 interspace, a 22-gauge needle with a Quincke tip was used to deliver spinal anesthesia to the patient. About 120 seconds after receiving an injection of 20 mg (4 ml) of hyperbaric bupivacaine 0.5%, the patient had significant back and gluteal discomfort, followed by myoclonic movements in the lower limbs and a generalized convulsion.\nThe arterial blood pressure of the patient was elevated to 170/100 mmHg, and his heart rate increased to 120 beats per minute. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. Phenytoin (1000 mg) was given by intravenous infusion and we subsequently applied the airway, breathing, and circulation (ABC) protocol. General anesthesia was induced by a thiopental sodium (250 mg) and atracurium (50 mg) infusion, the trachea of the patient was intubated, and respiratory parameters on mechanical ventilation were as follows: tidal volume (TV) 500 m/minute, respiratory rate (RR) 16 cycles/minute, fraction of inspired oxygen (FIO2) 100%, positive end-expiratory pressure (PEEP) 0 mmHg.\nMaintenance of anesthesia was attained by isoflurane 1.2 minimum alveolar concentration (MAC) and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. Although with the above interventions, the patient developed focal seizures in the hand and leg. The attending anesthesiologist had suspicions regarding intrathecal administration of the incorrect medicine after discovering a used TXA ampoule (500 mg/5 ml) in the trash. So, cerebrospinal fluid (CSF) lavage was done by inserting two spinal 22-gauge Quincke tip needles on level L2–L3 (drainage) and the other on L4–L5. Intrathecal normal saline infusion (150 ml) was done in 1 hour by passive flow. During CSF lavage, vital signs were as follows: blood pressure (BP) 140/85 mmHg, pulse 140 beats/minute, and the patient was on mechanical ventilation (MV) with FIO2 100 and oxygen saturation (SO2) 98%. Arterial blood gases (ABG) were pH 7.42, PaCO2 37, PaO2 157, and HCO3 24 after CSF lavage. The patient was stabilized, and he was transferred to the intensive care unit (ICU).\nAbout 2.5 hours after the injection, the patient was transferred to the ICU and with volume-controlled ventilation mode, the MV was continued. The patient was put on MV, and thiopental sodium infusion was continued, with 100 mg/hour increased to 300 mg/hour, but the patient developed multiple generalized myoclonic seizures so atracurium was started by loading 50 mg then 5–10 μg/kg/hour as apart of complete general anesthesia. However, the seizures were not controlled so we put the patient on an anesthesia machine and continued MV with isoflurane 1.2 MAC, with thiopental sodium 300 mg/hour and 10 μg/kg/hour atracurium.\nA central venous catheter was inserted on the right subclavian vein. The initial postoperative ABG examination showed pH of 7.44, PaO2 of 170, PaCO2 of 47, and HCO3− of 27. The MV parameter was adjusted to produce hyperventilation to target PaCo2 of 35–40 mmHg with continuous monitoring with capnogram. A complete blood test indicated no evidence of hepatic, renal, or hematological malfunction. Six hours postoperatively, the patient suffered tonico–clonic seizures of the upper limbs and face, which were managed by a continuous infusion of sodium thiopental (3–5 mg/kg/hour), atracurium 10 μg/kg/hour, isoflurane 1.2 MAC, and 150 mg phenytoin every 8 hours.\nCranial computed tomography revealed no abnormality and fundus examination revealed papilledema, so protective brain strategies continued with mannitol 20% 150 ml every 8 hours for 2 days and isoflurane 1.2 MAC and mild fluid restriction and lasix 20 mg every 12 hours. To avoid ventricular arrhythmia, amiodarone was administered prophylactically at a dose of 10 mg/kg/24 hours for 24 hours. The patient developed sinus tachycardia and his heart rate increased to 150 beats/minute, which was controlled by an amiodarone infusion. After 3 hours from admission to ICU, the patient’s blood pressure decreased, with mean arterial blood pressure below 50 mmHg, and investigations showed normal electrocardiogram (ECG) sinus rhythm. Central venous pressure (CVP) was 10 cm H2O, so norepinephrine infusion was started at 0.05 μg/kg/minute to maintain tissue and cerebral perfusion. The mean arterial blood pressure then improved with norepinephrine and maintained above 75 mmHg.\nOn the second day postoperatively, the sedation began to decrease: first isoflurane to reach 0.6 MAC, then isoflurane was stopped, and thiopental sodium was decreased to 200 mg/hour. The patient developed one-time seizures on the face and upper extremities, so sedation was continued for another 24 hours with decreasing thiopental sodium to 200 mg/hour only. Also, the patient became feverish (39 °C) in the second day so, 1 gm intravenous acetaminophen was given every 6 hours.\nNorepinephrine was stopped after 24 hours as mean arterial blood pressure was maintained over 75 mmHg without support.\nOn the third day after surgery, sedation was discontinued. As the patient’s degree of consciousness improved, he moved his head and upper extremities in response to painful stimuli and absence of deep tendon reflexes in the lower limbs. On the fourth day postoperatively, he opened his eyes in response to voice instructions, followed simple directions, and breathed on his own. The trachea was extubated, and all neurologic examinations were acceptable. The patient was discharged from the ICU on the sixth day and transferred to the ward after 48 hours from weaning from MV. The patient was discharged home with recommendation to follow-up with neurology and to be fully evaluated after 6 months. The patient was monitored at 6-month and 1-year intervals and found to be in excellent condition with no neurological symptoms.", + "fulltext_subclaims": [ + "The patient was a 31-year-old Egyptian male.", + "The patient had a history of polytrauma since 1 week.", + "The patient had a left arm and right leg fracture.", + "A complete trauma survey was done at the time of admission.", + "The operation was done first to the fracture on the left hand under general anesthesia.", + "The operation on the right leg was scheduled after 1 week.", + "A 22-gauge needle with a Quincke tip was used to deliver spinal anesthesia.", + "The patient received an injection of 20 mg (4 ml) of hyperbaric bupivacaine 0.5%.", + "About 120 seconds after the injection, the patient had significant back and gluteal discomfort.", + "The patient had myoclonic movements in the lower limbs.", + "The patient had a generalized convulsion.", + "The patient's arterial blood pressure was elevated to 170/100 mmHg.", + "The patient's heart rate increased to 120 beats per minute.", + "Midazolam (5 mg) was given intravenously.", + "Fentanyl (50 μg) was given intravenously.", + "Phenytoin (1000 mg) was given by intravenous infusion.", + "General anesthesia was induced by thiopental sodium (250 mg) and atracurium (50 mg).", + "The patient's trachea was intubated.", + "Maintenance of anesthesia was attained by isoflurane 1.2 minimum alveolar concentration (MAC).", + "The patient developed focal seizures in the hand and leg.", + "A used TXA ampoule (500 mg/5 ml) was found in the trash.", + "Cerebrospinal fluid (CSF) lavage was done.", + "Intrathecal normal saline infusion (150 ml) was done in 1 hour.", + "The patient was transferred to the intensive care unit (ICU).", + "The patient was put on volume-controlled ventilation mode.", + "Thiopental sodium infusion was increased to 300 mg/hour.", + "The patient developed multiple generalized myoclonic seizures.", + "A central venous catheter was inserted on the right subclavian vein.", + "The initial postoperative ABG showed pH of 7.44.", + "The MV parameter was adjusted to produce hyperventilation.", + "The patient suffered tonic–clonic seizures of the upper limbs and face.", + "Cranial computed tomography revealed no abnormality.", + "Fundus examination revealed papilledema.", + "Mannitol 20% 150 ml was given every 8 hours.", + "Amiodarone was administered prophylactically at 10 mg/kg/24 hours.", + "The patient developed sinus tachycardia.", + "Norepinephrine infusion was started at 0.05 μg/kg/minute.", + "The patient was discharged from the ICU on the sixth day.", + "The patient was transferred to the ward after 48 hours from weaning from MV.", + "The patient was discharged home with recommendation to follow-up with neurology.", + "The patient was monitored at 6-month and 1-year intervals.", + "The patient was found to be in excellent condition with no neurological symptoms." + ], + "summary": "In this case report, a 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain, myoclonus of the lower limbs, agitation, and widespread convulsions in a 31-year-old Egyptian male with history of left arm and right leg fracture. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. A 1000 mg phenytoin intravenous infusion and subsequently, induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion, and the trachea of the patient was intubated. Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. The patient developed focal seizures in the hand and leg, so cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles, one on level L2-L3 (drainage) and the other on L4-L5. Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow. After cerebrospinal fluid lavage and the patient's stabilization was obtained, he was transferred to the intensive care unit.", + "summary_subclaims": [ + "A 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain.", + "A 400 mg intrathecal injection of tranexamic acid resulted in myoclonus of the lower limbs.", + "A 400 mg intrathecal injection of tranexamic acid resulted in agitation.", + "A 400 mg intrathecal injection of tranexamic acid resulted in widespread convulsions.", + "Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered.", + "There was no response in seizure termination after midazolam and fentanyl.", + "A 1000 mg phenytoin intravenous infusion was performed.", + "Induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion.", + "The trachea of the patient was intubated.", + "Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration.", + "Maintenance of anesthesia was achieved by atracurium 10 mg every 20 minutes.", + "Subsequent doses of thiopental sodium (100 mg) were given to control seizures.", + "The patient developed focal seizures in the hand and leg.", + "Cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles.", + "One spinal needle was inserted on level L2-L3 for drainage.", + "One spinal needle was inserted on level L4-L5.", + "Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow.", + "After cerebrospinal fluid lavage and the patient's stabilization was obtained, he was transferred to the intensive care unit." + ] + }, + { + "id": "multiclinsum_test_2334_en.txt", + "fulltext": "A 71-year-old Iranian man developed severe right ear pain of three-week duration. He then developed a painful, vesicular eruption on the right side of his neck. With a presumptive diagnosis of herpes zoster reactivation, the patient was treated with oral acyclovir. However, he was re-admitted for an abrupt onset of facial weakness and mild vertigo. On examination, the patient had right-sided facial weakness . In addition, vesicular eruptions with adherent crusts and scabs (characteristic of VZV eruption) were noted within the right external auditory canal, over the mastoid, around the pinna, and C2-C3 cervical dermatomes (involvement of VII cranial nerve and C2-3 spinal nerves) . He had no associated immunocompromising condition including immunosuppressant drug use, leukemia, etc. A diagnosis of VZV reactivation from multiple ganglia was made based on the patient's characteristic presentation. The serum anti-VZV IgM antibody (ELISA) and VZV DNA (polymerase chain reaction) were negative. A computed tomography scan of the head was unremarkable. Further investigation revealed an increased white cell count (of 21600/μL) and a first hour erythrocyte sedimentation rate of 72 mm. The patient was placed on oral prednisone and oral acyclovir. A gradual improvement in facial weakness was noted. The herpetic vesicles on the head and neck were completely crusted. He was discharged with a favorable clinical condition.", + "fulltext_subclaims": [ + "The patient is a 71-year-old Iranian man.", + "He developed severe right ear pain of three-week duration.", + "He developed a painful, vesicular eruption on the right side of his neck.", + "The patient was treated with oral acyclovir.", + "He was re-admitted for an abrupt onset of facial weakness and mild vertigo.", + "On examination, the patient had right-sided facial weakness.", + "Vesicular eruptions with adherent crusts and scabs were noted within the right external auditory canal.", + "Vesicular eruptions with adherent crusts and scabs were noted over the mastoid.", + "Vesicular eruptions with adherent crusts and scabs were noted around the pinna.", + "Vesicular eruptions with adherent crusts and scabs were noted on the C2-C3 cervical dermatomes.", + "The patient had no associated immunocompromising condition.", + "A diagnosis of VZV reactivation from multiple ganglia was made.", + "The serum anti-VZV IgM antibody (ELISA) was negative.", + "The VZV DNA (polymerase chain reaction) was negative.", + "A computed tomography scan of the head was unremarkable.", + "The white cell count was 21600/μL.", + "The first hour erythrocyte sedimentation rate was 72 mm.", + "The patient was placed on oral prednisone.", + "The patient was placed on oral acyclovir.", + "A gradual improvement in facial weakness was noted.", + "The herpetic vesicles on the head and neck were completely crusted.", + "The patient was discharged with a favorable clinical condition." + ], + "summary": "Here, we report a 71-year-old Iranian man with involvement of multiple sensory ganglia (geniculate ganglion and upper dorsal root ganglia) by varicella-zoster virus. He presented with right-sided facial weakness along with vesicular eruptions on the right side of his neck, and second and third cervical dermatomes.", + "summary_subclaims": [ + "The patient is a 71-year-old Iranian man.", + "The patient had involvement of multiple sensory ganglia by varicella-zoster virus.", + "The geniculate ganglion was involved.", + "The upper dorsal root ganglia were involved.", + "The patient presented with right-sided facial weakness.", + "The patient had vesicular eruptions on the right side of his neck.", + "The patient had vesicular eruptions on the second cervical dermatome.", + "The patient had vesicular eruptions on the third cervical dermatome." + ] + }, + { + "id": "multiclinsum_test_1682_en.txt", + "fulltext": "A 21-year-old male patient was admitted with 1 month history of intermittent high grade fever. He also complained of weight loss, loss of appetite, generalized body weakness and hair loss. He was not on any long term drug treatment. On clinical examination, he appeared unwell, was febrile at 38.5ºC with mild pallor.\nHe also had a painful oral ulcer with bilateral cervical and right axillary nontender lymphadenopathy but there was no hepatosplenomegaly or bone tenderness. Other system examinations were unremarkable. Laboratory evaluation revealed normochromic normocytic anaemia (hemoglobin 9.9g/dl, RBC 3.9×1012/L), leucopenia (white cell count 2.06×109/L) and thrombocytopenia (platelet 75×109/L). Aspartate transaminase was 64.2 U/L, alanine transaminase 86.7 U/L, GGT 244.4 U/L (normal range 15–55 U/L) and lactate dehydrogenase was 757U/L (230-460 U/L). Alkaline phosphatase, serum albumin and bilirubin levels were normal. Erythrocyte sedimentation rate (ESR) was 55mm in 1st hour and C-reactive protein (CRP) was 3.8mg/L (<6).\nSerum ferritin increased at 1174.36ng/mL (20–159 ng/mL). Coagulation profile was normal. Urea, creatinine and urinalysis were normal. Infection screen for Epstein-Barr, cytomegalovirus, hepatitis B, hepatitis C and HIV viruses was negative. Toxoplasma gondii IgG antibody was positive with negative IgM. Blood and urine cultures were negative. Malarial parasites were not detected. Mantoux test was negative. The autoimmune profile revealed increased levels of double stranded (ds)-DNA antibody 133.3 IU/L (>46.1 IU/L is positive), C3 level was 46.1 mg/dL (normal range 90-180 mg/dL). Anti-nuclear antibody (ANA) was positive. Chest x-ray, electrocardiogram, echocardiogram and abdominal ultrasound were normal. Cervical lymph node biopsy revealed chronic reactive lymphadenopathy without neoplastic lymphoid cell proliferation. There was a reactive bone marrow. The diagnosis of SLE was made according to the American Collage of Rheumatology (ACR) diagnostic criteria, as he fulfilled four criteria including hematological involvement, oral ulcer, positive ANA and ds-DNA antibody. He was started on oral prednisolone 1mg/kg daily treatment. He made a dramatic clinical and biochemical improvement within one week and was discharged. He was reviewed at medical clinic regularly and corticosteroids were tailed off gradually. Currently, three months after the diagnosis, he is being managed with low-dose prednisolone, hydroxychloroquine and osteoporosis prophylaxis.", + "fulltext_subclaims": [ + "The patient was a 21-year-old male.", + "He had a 1 month history of intermittent high grade fever.", + "He complained of weight loss.", + "He complained of loss of appetite.", + "He complained of generalized body weakness.", + "He complained of hair loss.", + "He was not on any long term drug treatment.", + "On clinical examination, he appeared unwell.", + "He was febrile at 38.5ºC.", + "He had mild pallor.", + "He had a painful oral ulcer.", + "He had bilateral cervical and right axillary nontender lymphadenopathy.", + "There was no hepatosplenomegaly.", + "There was no bone tenderness.", + "Other system examinations were unremarkable.", + "Laboratory evaluation revealed normochromic normocytic anaemia.", + "Hemoglobin was 9.9g/dl.", + "RBC was 3.9×1012/L.", + "White cell count was 2.06×109/L.", + "Platelet count was 75×109/L.", + "Aspartate transaminase was 64.2 U/L.", + "Alanine transaminase was 86.7 U/L.", + "GGT was 244.4 U/L.", + "Lactate dehydrogenase was 757U/L.", + "Erythrocyte sedimentation rate was 55mm in 1st hour.", + "C-reactive protein was 3.8mg/L.", + "Serum ferritin was 1174.36ng/mL.", + "Infection screen for Epstein-Barr, cytomegalovirus, hepatitis B, hepatitis C and HIV viruses was negative.", + "Toxoplasma gondii IgG antibody was positive.", + "Toxoplasma gondii IgM antibody was negative.", + "Blood and urine cultures were negative.", + "Malarial parasites were not detected.", + "Mantoux test was negative.", + "The autoimmune profile revealed increased levels of double stranded (ds)-DNA antibody.", + "C3 level was 46.1 mg/dL.", + "Anti-nuclear antibody (ANA) was positive.", + "Cervical lymph node biopsy revealed chronic reactive lymphadenopathy.", + "There was a reactive bone marrow.", + "The diagnosis of SLE was made according to the American Collage of Rheumatology (ACR) diagnostic criteria.", + "He fulfilled four criteria including hematological involvement, oral ulcer, positive ANA and ds-DNA antibody.", + "He was started on oral prednisolone 1mg/kg daily treatment.", + "He made a dramatic clinical and biochemical improvement within one week.", + "He was discharged.", + "He was reviewed at medical clinic regularly.", + "Corticosteroids were tailed off gradually.", + "Currently, three months after the diagnosis, he is being managed with low-dose prednisolone.", + "He is being managed with hydroxychloroquine.", + "He is being managed with osteoporosis prophylaxis." + ], + "summary": "We report a 21-year-old male presented with one month history of fever, loss of appetite, weight loss and reduced hair growth with an examination revealing an oral ulcer, cervical and axillary lymphadenopathy simulating hematological malignancy. Investigations showed pancytopenia, positive anti-nuclear factor and double-stranded DNA, high erythrocyte sedimentation rate with normal C-reactive protein levels and hypocomplementemia. The diagnosis of systemic lupus erythematosus was made and treatment with oral prednisolone conferred a dramatic clinical and biochemical improvement within one week.", + "summary_subclaims": [ + "The patient is a 21-year-old male.", + "The patient had a one month history of fever.", + "The patient had loss of appetite.", + "The patient had weight loss.", + "The patient had reduced hair growth.", + "An oral ulcer was found on examination.", + "Cervical lymphadenopathy was present.", + "Axillary lymphadenopathy was present.", + "The lymphadenopathy simulated hematological malignancy.", + "Investigations showed pancytopenia.", + "Anti-nuclear factor was positive.", + "Double-stranded DNA was positive.", + "Erythrocyte sedimentation rate was high.", + "C-reactive protein levels were normal.", + "Hypocomplementemia was present.", + "The diagnosis was systemic lupus erythematosus.", + "Treatment with oral prednisolone conferred a dramatic clinical improvement within one week.", + "Treatment with oral prednisolone conferred a dramatic biochemical improvement within one week." + ] + }, + { + "id": "multiclinsum_test_2365_en.txt", + "fulltext": "The patient was a 64-year-old retired woman from Yichang, Hubei Province with a past medical history of cholecystectomy for cholecystitis 25 years prior. She had no history of hypertension, hyperlipidemia, or diabetes. The patient presented with characteristic electric shock-like, lancinating pain in the right V2 distribution area accompanied by right pulsatile tinnitus. The pain was triggered by innocuous stimuli such as brushing teeth or washing her face over the affected trigeminal dermatomes. She was first treated with oxcarbazepine 450 mg daily for 1 month without significant relief. She was then switched to carbamazepine 200 mg daily, which provided initial control of her symptoms for 2 months. However, the pain gradually worsened, requiring an increase in carbamazepine to 600 mg daily. At this higher dosage, discomfort such as dizziness occurred, and the pain was still uncontrollable.\nMagnetic resonance imaging showed multiple vascular flow void signals in the right cisternal segment near the trigeminal nerve. Further cerebral angiography revealed a right arteriovenous fistula that was supplied by the petrous branch of the middle meningeal artery of the right external carotid artery and the posterior meningeal artery branch of the right vertebral artery (A&B). The fistula was located between the tentorial dura mater and drained through the superior petrosal vein (SPV) to the basal vein (Borden class III). Hence, interventional embolization was performed through the enlarged right external carotid artery to the posterior branch of the middle meningeal artery. During the operation, a Marathon microcatheter was used for superselection to the fistula; the onyx spread well and the casting was satisfactory. Following embolization, the patient's pulsatile tinnitus resolved, however TN recurred on postoperative day 3 with identical location and characteristics as her preoperative pain. Her postoperative medical regimen consisted of carbamazepine 400 mg daily and the addition of pregabalin 300 mg daily in an attempt to control her persistent facial pain. According to the patient, this adjustment provided a modest decrease in frequency of painful paroxysms, though her symptoms remained suboptimally controlled. Six months postoperatively, follow-up angiography revealed complete obliteration of the DAVF .\nTherefore, we decided to perform MVD via the retrosigmoid approach for this patient. Preoperative re-examination of the T2-constructive interference in steady state (CISS) high-resolution nuclear magnetic resonance sequence showed that the vascular flow void signal was significantly reduced compared with that before embolization, but the significantly expanded flow void signal near the trigeminal cisternal segment could still be seen (C). During the operation, the SPV was found to be tortuously dilated and formed a venous lake. The blood vessels showed a post-embolization appearance, were dark blue, and had no arterial pulsation. The pontotrigeminal vein, which joins the SPV from the ventral side, was also tortuously dilated, dark blue in color, and hard in texture, and venous thrombosis was considered. The dilated vein pushed down the trigeminal cisternal segment from the ventral side (A). We attempted to separate the neurovascular vessels with spherical microvascular strippers, but the thrombosed veins were severely sclerotic and difficult to move. Therefore, bipolar coagulation was used to reduce the diameter of the vein in the intermittent 7 W of power so that the trigeminal cistern was no longer compressed. A Teflon pad was then placed between the draining vein and the trigeminal cisternal segment to further open the nerve–vessel space, and the branch of the superior cerebellar artery was found to form compression; therefore, we routinely used a Teflon pad on the responsible blood vessel in the REZ (D). The patient's right facial pain disappeared immediately postoperatively, and she had transient facial numbness that disappeared 3 weeks postoperatively.", + "fulltext_subclaims": [ + "The patient was a 64-year-old retired woman from Yichang, Hubei Province.", + "She had a past medical history of cholecystectomy for cholecystitis 25 years prior.", + "She had no history of hypertension, hyperlipidemia, or diabetes.", + "The patient presented with characteristic electric shock-like, lancinating pain in the right V2 distribution area.", + "The pain was accompanied by right pulsatile tinnitus.", + "The pain was triggered by innocuous stimuli such as brushing teeth or washing her face over the affected trigeminal dermatomes.", + "She was first treated with oxcarbazepine 450 mg daily for 1 month without significant relief.", + "She was then switched to carbamazepine 200 mg daily, which provided initial control of her symptoms for 2 months.", + "The pain gradually worsened, requiring an increase in carbamazepine to 600 mg daily.", + "At this higher dosage, discomfort such as dizziness occurred.", + "The pain was still uncontrollable.", + "Magnetic resonance imaging showed multiple vascular flow void signals in the right cisternal segment near the trigeminal nerve.", + "Cerebral angiography revealed a right arteriovenous fistula.", + "The fistula was supplied by the petrous branch of the middle meningeal artery of the right external carotid artery and the posterior meningeal artery branch of the right vertebral artery.", + "The fistula was located between the tentorial dura mater.", + "The fistula drained through the superior petrosal vein to the basal vein (Borden class III).", + "Interventional embolization was performed through the enlarged right external carotid artery to the posterior branch of the middle meningeal artery.", + "A Marathon microcatheter was used for superselection to the fistula.", + "Onyx spread well and the casting was satisfactory.", + "Following embolization, the patient's pulsatile tinnitus resolved.", + "Trigeminal neuralgia recurred on postoperative day 3 with identical location and characteristics as her preoperative pain.", + "Her postoperative medical regimen consisted of carbamazepine 400 mg daily and the addition of pregabalin 300 mg daily.", + "This adjustment provided a modest decrease in frequency of painful paroxysms.", + "Her symptoms remained suboptimally controlled.", + "Six months postoperatively, follow-up angiography revealed complete obliteration of the DAVF.", + "We decided to perform MVD via the retrosigmoid approach for this patient.", + "Preoperative re-examination of the T2-CISS high-resolution nuclear magnetic resonance sequence showed that the vascular flow void signal was significantly reduced compared with that before embolization.", + "The significantly expanded flow void signal near the trigeminal cisternal segment could still be seen.", + "During the operation, the SPV was found to be tortuously dilated and formed a venous lake.", + "The blood vessels showed a post-embolization appearance, were dark blue, and had no arterial pulsation.", + "The pontotrigeminal vein, which joins the SPV from the ventral side, was also tortuously dilated, dark blue in color, and hard in texture.", + "Venous thrombosis was considered.", + "The dilated vein pushed down the trigeminal cisternal segment from the ventral side.", + "We attempted to separate the neurovascular vessels with spherical microvascular strippers.", + "The thrombosed veins were severely sclerotic and difficult to move.", + "Bipolar coagulation was used to reduce the diameter of the vein in the intermittent 7 W of power.", + "A Teflon pad was then placed between the draining vein and the trigeminal cisternal segment.", + "The branch of the superior cerebellar artery was found to form compression.", + "A Teflon pad was routinely used on the responsible blood vessel in the REZ.", + "The patient's right facial pain disappeared immediately postoperatively.", + "She had transient facial numbness that disappeared 3 weeks postoperatively." + ], + "summary": "We herein report a case of TN secondary to a DAVF in a 64-year-old woman with a 1-year history of right-sided TN. Brain magnetic resonance imaging and digital subtraction angiography showed a right tentorial DAVF. Interventional embolization was performed, but the pain was not relieved after the operation. Six months later, we performed microvascular decompression of the trigeminal nerve. During the operation, we electrocoagulated the tortuous and dilated malformed vein, which was compressing the trigeminal nerve, to reduce its diameter and mitigate the compression on the cisternal segment of the trigeminal nerve. That patient's pain was relieved postoperatively. In addition, we reviewed the literature of TN caused by DAVF and found a total of 30 cases, 22 of which were treated by interventional embolization. Of these 22 cases, the interventional embolization healed the fistula with pain relief in 14 cases and healed the fistula without pain relief in 8 cases. We found that the venous drainage methods of the 8 cases were all classified into the posterior mesencephalic group.", + "summary_subclaims": [ + "The patient was a 64-year-old woman.", + "She had a 1-year history of right-sided trigeminal neuralgia (TN).", + "Brain magnetic resonance imaging and digital subtraction angiography showed a right tentorial dural arteriovenous fistula (DAVF).", + "Interventional embolization was performed.", + "The pain was not relieved after the operation.", + "Six months later, microvascular decompression of the trigeminal nerve was performed.", + "During the operation, the tortuous and dilated malformed vein compressing the trigeminal nerve was electrocoagulated.", + "The electrocoagulation reduced the diameter of the vein.", + "The electrocoagulation mitigated the compression on the cisternal segment of the trigeminal nerve.", + "The patient's pain was relieved postoperatively.", + "A literature review found a total of 30 cases of TN caused by DAVF.", + "Of these 30 cases, 22 were treated by interventional embolization.", + "In 14 of the 22 cases, interventional embolization healed the fistula with pain relief.", + "In 8 of the 22 cases, interventional embolization healed the fistula without pain relief.", + "The venous drainage methods of the 8 cases were all classified into the posterior mesencephalic group." + ] + }, + { + "id": "multiclinsum_test_1566_en.txt", + "fulltext": "A 31-year-old woman presented at our Department due to infertility. Her medical history was unremarkable except unsuccessful attempts for pregnancy for the past 2.5 years. She had regular menstrual cycles since the age of 13 years. On clinical examination, she was normotensive and normokalemic without clinical signs of Cushing’s syndrome or hyperandrogenism. Her height, BMI and glucose homeostasis and bone mineral density proved to be normal (height: 170 cm, BMI: 19.8 kg/m2, fasting serum glucose: 5.0 mmol/l and HbA1c: 5.2%), and galactorrhoea was absent. Family history was also unremarkable. Initial laboratory findings indicated an increased serum prolactin level (93 ng/ml; reference range: 1.4–24 ng/ml), but this was due to macroprolactinemia (prolactin recovery after polyethylene glycol: PEG precipitation was 76%). Magnetic resonance imaging did not reveal any pituitary abnormality. A paternal cause of infertility was unlikely because her husband already had two children from his previous marriage. Detailed hormone laboratory investigations of the index patient suggested a partial resistance against glucocorticoids . After genetic counseling and written informed consent, Sanger sequencing of the coding region of the GR gene was performed. After identification of a pathogenic GR mutation, a family screening was indicated for the first degree relatives. Her 35-year-old, clinically healthy sister, who has no fertility problems (mother of a 10-year-old girl) was also genetically tested.\nAll patients and family members underwent genetic counseling and informed consent for genetic testing was obtained from all individuals. Evaluation and treatment of human data have been performed in accordance with the Declaration of Helsinki and the study was approved by the Local Ethical Committee of Semmelweis University.\nLaboratory measurements were performed at the Central Laboratory of Semmelweis University. Fasting blood samples were obtained between 08:00 and 09:00 h. Plasma, salivary and urinary cortisol and plasma ACTH, serum estradiol, progesterone, sex hormone binding globulin (SHBG), testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), free thyroxin (fT4), prolactin and growth hormone (GH) concentrations were measured with an electrochemiluminescence immunoassay (Cobas E411, ROCHE, Indianapolis; Architect System, Lisnamuck, Longford, Ireland; IDS-iSYS, Immunodiagnostic Systems Ltd., Boldon, England), while serum dehydroepiandrosterone sulphate (DHEAS) and androstendione concentrations were determined with radioimmunoassay (Beckman Coulter Brea, California, USA).\nDNA was isolated from peripheral blood by a standard procedure using commercially available DNA isolation reagents (DNA Isolation kit from blood, Qiagen, San Diego, USA). The whole coding region of the GR was evaluated by Sanger sequencing as previously described by Koper et al. .\nTable summarises the main hormone laboratory findings of the index patient. During repeated measurements, serum cortisol levels in the morning were always elevated (between 26 and 35.4 μg/dl; reference range: 8–25 μg/dl) while plasma ACTH concentration was slightly above the upper limit or within the normal range (between 28.5 and 65 pg/ml; reference range: 7.2–63.3). Morning salivary cortisol levels (determined two times) were also elevated (1.36 and 1,13 μg/dl; reference range: < 0.690) but salivary cortisol collected at midnight was within the reference range (0.21 and 0.23 μg/dl; reference range < 0.430 μg/dl). A low dose (1 mg) overnight dexamethasone suppression test was performed twice, and showed an inadequate suppression of morning serum cortisol (10 and 15 μg/dl; reference range: l < 1.8 μg/dl). Repeated 24 h urinary free cortisol (UFC) concentrations were between 280 and 513 nmol/day (reference range: 100–379). Serum DHEAS was slightly elevated or normal (342 and 163 μg/dl, reference range: 130–330), and serum androstendione was increased (344 ng/dl; reference range 80-280 ng/dl). GH, SHBG, TSH, fT4, LH, FSH, testosterone, progesterone and estradiol levels were all normal (not shown in Table ).\nAs shown in Fig. , a heterozygous missense mutation (c.2141G➔A) resulting in a Arg714Gln change was identified in exon 8 of the GR gene. The same mutation was found in the clinically healthy 35-year-old sister of the patient, who had normal steroid hormone levels. Other family members denied the clinical, genetic or hormonal screening. In addition, this variant was not detected in more than 60 patients and controls tested either for glucocorticoid resistance or Cushing’s syndrome in our Laboratory. Moreover it was not present in commonly used genetic databases including Exome Variant Server , Exac and SNPeffect .\nMolecular modeling and analyses were performed using the UCSF Chimera package . The coordinates of the GR ligand binding domain have been obtained from PDB structure 4UDC. Arginine at the position 714 is the member of helix 10 of the ligand binding domain (LBD) of the GR. It locates opposite side of the ligand binding pocket and relatively far from any known functional region. However, arginine has a large, positively charged side chain, which protrudes into a space created by helices 7–10 , but glutamine has a smaller, uncharged side chain, which may release helix 10 from its original position, which may lead to further conformational changes in the ligand-binding pocket. Nader et al. performed a complex functional testing of this mutation and using the quantification of the thickness of both the wild type and mutant Cα showed that the mutant LBD had an increased distance in root mean square deviation over the duration of the simulation compared to the wild type receptor, suggesting that the mutant structure binds the peptide with less affinity .", + "fulltext_subclaims": [ + "The patient is a 31-year-old woman.", + "She presented due to infertility.", + "Her medical history was unremarkable except for unsuccessful attempts for pregnancy for the past 2.5 years.", + "She had regular menstrual cycles since the age of 13 years.", + "On clinical examination, she was normotensive.", + "On clinical examination, she was normokalemic.", + "There were no clinical signs of Cushing’s syndrome.", + "There were no clinical signs of hyperandrogenism.", + "Her height was 170 cm.", + "Her BMI was 19.8 kg/m2.", + "Fasting serum glucose was 5.0 mmol/l.", + "HbA1c was 5.2%.", + "Galactorrhoea was absent.", + "Family history was unremarkable.", + "Initial laboratory findings indicated an increased serum prolactin level of 93 ng/ml.", + "The increased serum prolactin was due to macroprolactinemia.", + "Magnetic resonance imaging did not reveal any pituitary abnormality.", + "A paternal cause of infertility was unlikely.", + "Her husband already had two children from his previous marriage.", + "Detailed hormone laboratory investigations suggested a partial resistance against glucocorticoids.", + "Sanger sequencing of the coding region of the GR gene was performed after genetic counseling and written informed consent.", + "A pathogenic GR mutation was identified.", + "Family screening was indicated for the first degree relatives.", + "Her 35-year-old, clinically healthy sister was also genetically tested.", + "All patients and family members underwent genetic counseling.", + "Informed consent for genetic testing was obtained from all individuals.", + "Evaluation and treatment of human data were performed in accordance with the Declaration of Helsinki.", + "The study was approved by the Local Ethical Committee of Semmelweis University.", + "Laboratory measurements were performed at the Central Laboratory of Semmelweis University.", + "Fasting blood samples were obtained between 08:00 and 09:00 h.", + "Plasma, salivary and urinary cortisol and plasma ACTH were measured with an electrochemiluminescence immunoassay.", + "Serum estradiol, progesterone, SHBG, testosterone, LH, FSH, TSH, fT4, prolactin and GH concentrations were measured with an electrochemiluminescence immunoassay.", + "Serum DHEAS and androstendione concentrations were determined with radioimmunoassay.", + "DNA was isolated from peripheral blood using a DNA Isolation kit from blood.", + "The whole coding region of the GR was evaluated by Sanger sequencing.", + "During repeated measurements, serum cortisol levels in the morning were always elevated.", + "Plasma ACTH concentration was slightly above the upper limit or within the normal range.", + "Morning salivary cortisol levels were elevated.", + "A low dose (1 mg) overnight dexamethasone suppression test showed an inadequate suppression of morning serum cortisol.", + "24 h urinary free cortisol concentrations were between 280 and 513 nmol/day.", + "Serum DHEAS was slightly elevated or normal.", + "Serum androstendione was increased.", + "GH, SHBG, TSH, fT4, LH, FSH, testosterone, progesterone and estradiol levels were all normal.", + "A heterozygous missense mutation (c.2141G➔A) resulting in a Arg714Gln change was identified in exon 8 of the GR gene.", + "The same mutation was found in the clinically healthy 35-year-old sister of the patient.", + "The sister had normal steroid hormone levels.", + "Other family members denied the clinical, genetic or hormonal screening.", + "The variant was not detected in more than 60 patients and controls tested either for glucocorticoid resistance or Cushing’s syndrome.", + "The variant was not present in commonly used genetic databases including Exome Variant Server, Exac and SNPeffect.", + "Molecular modeling and analyses were performed using the UCSF Chimera package.", + "The coordinates of the GR ligand binding domain were obtained from PDB structure 4UDC.", + "Arginine at the position 714 is the member of helix 10 of the ligand binding domain of the GR.", + "Arginine locates opposite side of the ligand binding pocket.", + "Arginine is relatively far from any known functional region.", + "Arginine has a large, positively charged side chain.", + "Glutamine has a smaller, uncharged side chain.", + "The mutant LBD had an increased distance in root mean square deviation over the duration of the simulation compared to the wild type receptor.", + "The mutant structure binds the peptide with less affinity." + ], + "summary": "A 31-year-old woman was evaluated because of infertility at the Endocrine Unit of the 2nd Department of Medicine, Semmelweis University. During her laboratory investigations, elevated serum and salivary cortisol were observed which failed to be suppressed after administration of 1 mg dexamethasone. 24 h urinary cortisol was increased, but a normal midnight serum cortisol was detected suggesting a maintained circadian rhythm. Plasma dehydroepiandrosterone-sulfate and androstendione levels were also elevated. Repeated plasma ACTH measurements indicated slightly elevated or normal values. Bone mineral density was normal. All laboratory results confirmed the diagnosis of glucocorticoid resistance. Genetic counseling followed by Sanger sequencing of the coding region of the gene encoding human glucocorticoid receptor was performed and a missense mutation (Arg714Gln, R714Q) in a heterozygous form was detected. Following family screening, the same mutation was found in her clinically-healthy 35-year-old sister who had no fertility problems.This variant was not detected in more than 60 patients and controls tested either for glucocorticoid resistance or Cushing's syndrome in our Laboratory and it was absent in Exome Variant Server, HumanGene Mutation Database and ExAC databases.", + "summary_subclaims": [ + "A 31-year-old woman was evaluated because of infertility at the Endocrine Unit of the 2nd Department of Medicine, Semmelweis University.", + "Elevated serum and salivary cortisol were observed.", + "Elevated serum and salivary cortisol failed to be suppressed after administration of 1 mg dexamethasone.", + "24 h urinary cortisol was increased.", + "A normal midnight serum cortisol was detected.", + "Plasma dehydroepiandrosterone-sulfate levels were elevated.", + "Plasma androstendione levels were elevated.", + "Repeated plasma ACTH measurements indicated slightly elevated or normal values.", + "Bone mineral density was normal.", + "All laboratory results confirmed the diagnosis of glucocorticoid resistance.", + "Sanger sequencing of the coding region of the gene encoding human glucocorticoid receptor was performed.", + "A missense mutation (Arg714Gln, R714Q) in a heterozygous form was detected.", + "The same mutation was found in her clinically-healthy 35-year-old sister.", + "The variant was not detected in more than 60 patients and controls tested either for glucocorticoid resistance or Cushing's syndrome in our Laboratory.", + "The variant was absent in Exome Variant Server, HumanGene Mutation Database and ExAC databases." + ] + }, + { + "id": "multiclinsum_test_3003_en.txt", + "fulltext": "A 67-Year-old male presented to the emergency department with complaints of intermittent high-grade fever that started two days ago relieved by antipyretics prior to admission, which was associated with productive cough and shortness of breath. He had no significant history or chronic illness. He denied recent travel. On examination, the patient looked ill, confused, febrile, had tachypnea, tachycardia, mild pallor, and no lower limb edema. The Glasgow Coma Scale (GCS) was 13 (Eye 3, Verbal 4, and Motor 6). On the chest, there was reduced air entry and crackles on the right side of the lung. On admission vital signs were as follows: SpO2 90% on room air; blood pressure, 105/68 mmHg; pulse, 116 beats/min; respiratory rate 24, blood glucose, 69 122 mg/dl.\n\nThe initial laboratory investigation revealed white blood cell count 18.04 x10^9/L (normal 4.00–71 10.00 x10^9/L), hemoglobin 12.1 g/dl (normal 12.0–16.0 g/dl), platelet 450x10^9/L (normal 100–300x10^9/L), C-reactive protein 230.73 mg/L (normal 2.5–10 mg/L), aspartate transaminase (AST) 60.7 U/I (normal 6–38 U/I), alanine transaminase (ALT) 36.0 U/I (normal 6–40 U/I), serum creatinine 2.1 mg/dl (normal 0.4–1.4 mg/dl), and serum urea 170.5 mg/dl (10–50 mg/dl), sodium 135.9 mmol/l ((normal 135.0–145.0 mmol/l), potassium 5.3 mmol/l (normal 3.5–5.5 mmol/l), calcium 2.4 mmol/l (normal 2.10–2.70 mmol/l), COVID-19 test was negative.\n\nChest radiography was performed immediately and showed right upper lobe consolidation. The patient was admitted to the ward with community-acquired pneumonia and acute kidney injury (AKI) and started Ceftriaxone 1 g two times a day, intravenous fluid of normal saline (NS) 1 Liter per 24 h, ipratropium with ventolin inhaler four times a day,paracetamol 1000 mg infusion once a day, and nasal oxygen support 2 L per hour. After 12 hours, the patient’s condition deteriorated and developed respiratory distress and hypoxia with oxygen saturation 80% on a simple mask of 6L/hour, and was transferred to the intensive care unit (ICU) for supplemental oxygen therapy and further management. 24 hours later in the ICU, the patient’s urine appeared dark-colored and urine analysis revealed no hematuria, suggesting rhabdomyolysis. Laboratory investigation revealed white blood cell count 28.04 x10^9/L (normal 4.00–10.00 x10^9/L), 87 hemoglobin 11.2 g/dl (normal 12.0–16.0 g/dl), platelet 430x10^9/L (normal 100–300x10^9/L), C-reactive protein 300.73 mg/L (normal 2.5–10 mg/L),Creatinine kinase (CK) 4450 u/l (normal 1–171 u/l) serum myoglobin 389 ng/mL (normal 0–80 ng/mL),serum creatinine 2.5 mg/dl (normal 0.4–1.4 mg/dl), and serum urea 194.3 mg/dl (10–50 mg/dl),sodium 137.2 mmol/l ((normal 135.0–145.0 mmol/l), potassium 5.9 mmol/l (normal 3.5–5.5 mmol/l), calcium 1.9 mmol/l (normal 2.10–2.70 mmol/l),aspartate transaminase (AST) 84.7 U/I (normal 6–38 U/I), alanine transaminase (ALT) 40.5 U/I (normal 6–40 U/I) after that our previous diagnose changed for community acquired pneumonia associated with acute kidney injury complicating rhabdomyolysis and electrolyte imbalance so we change our plan for immediate and started with intravenous fluid Normal saline (ns) 5 liter per 24 hour along with adding sodium bicarbonate, piperacillin and tazobactam 2.25 g three times a day, moxifloxacin 400 mg for once a day. We maintained the intravenous fluid according to the dehydration status and urine output. After six days in the ICU, the patient improved and was switched to a nasal oxygen cannula, and laboratory investigations improved.\n\nSubsequently, the patient was transferred to the ward for continued management. A 10th days on admission a chest X-ray was performed and showed normal, clinically improved, and normal laboratory investigations. Finally, the patient was discharged, and follow-up was planned.", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "He presented with intermittent high-grade fever that started two days ago.", + "The fever was relieved by antipyretics prior to admission.", + "The fever was associated with productive cough.", + "The fever was associated with shortness of breath.", + "He had no significant history of chronic illness.", + "He denied recent travel.", + "On examination, the patient looked ill.", + "On examination, the patient was confused.", + "On examination, the patient was febrile.", + "On examination, the patient had tachypnea.", + "On examination, the patient had tachycardia.", + "The Glasgow Coma Scale (GCS) was 13.", + "On the chest, there was reduced air entry.", + "On the chest, there were crackles on the right side of the lung.", + "On admission, SpO2 was 90% on room air.", + "On admission, blood pressure was 105/68 mmHg.", + "On admission, pulse was 116 beats/min.", + "On admission, respiratory rate was 24.", + "On admission, blood glucose was 69–122 mg/dl.", + "The initial white blood cell count was 18.04 x10^9/L.", + "The initial hemoglobin was 12.1 g/dl.", + "The initial platelet count was 450x10^9/L.", + "The initial C-reactive protein was 230.73 mg/L.", + "The initial aspartate transaminase (AST) was 60.7 U/I.", + "The initial alanine transaminase (ALT) was 36.0 U/I.", + "The initial serum creatinine was 2.1 mg/dl.", + "The initial serum urea was 170.5 mg/dl.", + "The initial sodium was 135.9 mmol/l.", + "The initial potassium was 5.3 mmol/l.", + "The initial calcium was 2.4 mmol/l.", + "The initial COVID-19 test was negative.", + "Chest radiography showed right upper lobe consolidation.", + "The patient was admitted to the ward with community-acquired pneumonia.", + "The patient was admitted with acute kidney injury.", + "The patient was started on Ceftriaxone 1 g two times a day.", + "The patient was started on intravenous fluid of normal saline 1 Liter per 24 h.", + "The patient was started on ipratropium with ventolin inhaler four times a day.", + "The patient was started on paracetamol 1000 mg infusion once a day.", + "The patient was started on nasal oxygen support 2 L per hour.", + "After 12 hours, the patient’s condition deteriorated.", + "After 12 hours, the patient developed respiratory distress.", + "After 12 hours, the patient had oxygen saturation 80% on a simple mask of 6L/hour.", + "The patient was transferred to the ICU.", + "In the ICU, the patient’s urine appeared dark-colored.", + "In the ICU, urine analysis revealed no hematuria.", + "In the ICU, the white blood cell count was 28.04 x10^9/L.", + "In the ICU, hemoglobin was 11.2 g/dl.", + "In the ICU, platelet count was 430x10^9/L.", + "In the ICU, C-reactive protein was 300.73 mg/L.", + "In the ICU, creatinine kinase (CK) was 4450 u/l.", + "In the ICU, serum myoglobin was 389 ng/mL.", + "In the ICU, serum creatinine was 2.5 mg/dl.", + "In the ICU, serum urea was 194.3 mg/dl.", + "In the ICU, sodium was 137.2 mmol/l.", + "In the ICU, potassium was 5.9 mmol/l.", + "In the ICU, calcium was 1.9 mmol/l.", + "In the ICU, aspartate transaminase (AST) was 84.7 U/I.", + "In the ICU, alanine transaminase (ALT) was 40.5 U/I.", + "The previous diagnosis was changed to community-acquired pneumonia associated with acute kidney injury complicating rhabdomyolysis and electrolyte imbalance.", + "Intravenous fluid of normal saline 5 liters per 24 hour was started.", + "Sodium bicarbonate was added.", + "Piperacillin and tazobactam 2.25 g three times a day were started.", + "Moxifloxacin 400 mg once a day was started.", + "Intravenous fluid was maintained according to the dehydration status and urine output.", + "After six days in the ICU, the patient improved.", + "After six days in the ICU, the patient was switched to a nasal oxygen cannula.", + "After six days in the ICU, laboratory investigations improved.", + "The patient was transferred to the ward.", + "On the 10th day of admission, a chest X-ray was performed.", + "On the 10th day of admission, the chest X-ray showed normal.", + "On the 10th day of admission, the patient was clinically improved.", + "On the 10th day of admission, laboratory investigations were normal.", + "The patient was discharged.", + "Follow-up was planned." + ], + "summary": "A 67-year-old male presented with high fever, cough, and shortness of breath. He had no significant medical history. On examination, he was febrile, tachypneic, and tachycardic, with right-sided lung crackles. Lab tests showed elevated inflammatory markers and impaired kidney function. Chest radiography revealed right upper lobe consolidation, confirming pneumonia and AKI. He was treated with fluids, antibiotics, and supportive care, but his condition worsened, requiring intensive care unit (ICU). In the ICU, dark urine and elevated creatine kinase confirmed rhabdomyolysis. After aggressive fluid therapy and antibiotics the patient improved over six days and was transferred to the ward. By day 10, he fully recovered and was discharged with follow-up.", + "summary_subclaims": [ + "The patient is a 67-year-old male.", + "The patient presented with high fever.", + "The patient had cough.", + "The patient had shortness of breath.", + "The patient had no significant medical history.", + "On examination, the patient was febrile.", + "On examination, the patient was tachypneic.", + "On examination, the patient was tachycardic.", + "Right-sided lung crackles were heard on examination.", + "Lab tests showed elevated inflammatory markers.", + "Lab tests showed impaired kidney function.", + "Chest radiography revealed right upper lobe consolidation.", + "Pneumonia was confirmed.", + "Acute kidney injury was confirmed.", + "The patient was treated with fluids.", + "The patient was treated with antibiotics.", + "The patient received supportive care.", + "The patient's condition worsened.", + "The patient was transferred to the ICU.", + "In the ICU, dark urine was noted.", + "Elevated creatine kinase confirmed rhabdomyolysis.", + "After aggressive fluid therapy and antibiotics, the patient improved over six days.", + "The patient was transferred to the ward.", + "By day 10, the patient fully recovered.", + "The patient was discharged with follow-up." + ] + }, + { + "id": "multiclinsum_test_1776_en.txt", + "fulltext": "In June 2017, a 49-year-old Chinese woman was admitted to the emergency department of the Northern Jiangsu People’s Hospital owing to chest tightness and breathing difficulty that persisted for 3 days. She was previously in good health and was a non-smoker. In addition, she had fever, chills, and a maximum body temperature of 38 °C. She did not have urinary or fecal incontinence, chest pain, general fatigue, cough, or hemoptysis during the course of her disease. Following admission, results of complete blood test revealed that white blood cell count was 12.21 × 109 cells/L and the percentage of large white blood cells was 85.5%. Blood gas analysis results showed 7.480 PH, 100 mmHg PaO2, 31 mmHg PaCO2, and 23.1 mmol/L HCO3−. D-dimer assay indicated a value of 5.28 mg/L. A computed tomography pulmonary angiography (CTPA) revealed filling defects in the main pulmonary artery, upper and lower pulmonary artery branch . There were no distinct signs of embolism in color ultrasonography examination of the upper and lower limbs. The patient was diagnosed with PE, and was treated with anticoagulation, antiplatelet aggregation, and anti-infection medications. During the 18 h after admission, the patient experienced worsening shortness of breath and anoxia and was subsequently transferred to the Emergency Intensive Care Unit (EICU) for non-invasive ventilator assisted ventilation. Additionally, the patient was intravenously administered alteplase once every 12 h for 3 consecutive days and 5000 units subcutaneous unfractionated heparin. Warfarin (5 mg) was orally administered once a day. On noting that the prothrombin time (PT) and international normalized ratio (INR) were 2–2.5 times their respective normal levels, warfarin therapy was singly administered along with anti-infective, supportive, and oxygen therapies. Once her condition had considerably improved and the anoxia was reduced, she was discharged from the hospital.\nAfter 10 days, dyspnea and chest tightness recurred. In addition, she experienced persistent right chest pain, which aggravated when she lied on her right side and was not relieved by rest. Minor vaginal bleeding was also observed. She presented to the Department of Respiratory and Critical Care Medicine of our hospital for a CTPA, which revealed filling defects in the left and right branches of pulmonary artery as well as bilateral pleural effusion . A routine coagulation test revealed 37 s PT and 3.33 INR, and a D-dimer assay showed a value of 8.75 mg/L. No abnormalities were observed in limb color ultrasonography, tumor antigen testing, or surrogate markers of autoimmune diseases (anti-nuclear antibody, anti-RNP antibody, anti-CCP antibody, c-ANCA, p-ANCA, anti-SS-A antibody, and anti-SS-B antibody). Based on the monitoring of PT and INR, we decided to discontinue warfarin to prevent an overdose situation. Relevant contraindications were excluded and the patient underwent interventional inferior vena cava filter implantation combined with thrombolysis implantation therapy, along with low-dose urokinase. Following surgery, she continued to receive anticoagulant treatment. On considerably improvement in her condition, she was discharged.\nOne month later, she was referred to our hospital again due to swelling in her right lower limb. She received interventional inferior right iliac vein dilation and stent placement. In October 2018, she presented again with a week-long history of right-sided chest pain, cough, difficulty in breathing, and weight loss. A CTPA revealed no evident improvement of the thrombosis in the right and left main pulmonary artery, progression of pneumonia, and a reduced right pleural effusion, compared with the previous CTPA. Once again, the tumor associated antigen test was performed. Tumor antigen testing revealed an elevated Ca125 level of 69.16 U/ml (normal value < 35 U/ml) and Ca199 level of 30.22 U/ml (normal value < 27 U/ml). She was treated with anticoagulation, anti-infection, supportive, and oxygen therapies. We recommended her to undergo a positron emission tomography-computed tomography (PET-CT) test, but she refused and was discharged from the hospital.\nShe subsequently underwent a PET-CT examination in another hospital. The PET-CT revealed diffuse heterogeneous thickening of the right pleura, substantially increased glucose metabolism, fluorodeoxyglucose (FDG) uptake on L5 vertebral body, striated soft tissue lesions along the right iliac vein, and increased FDG uptake. In November 2018, she was once again admitted to our hospital. Results of enhanced chest CT scan revealed a bilateral PE, bilateral pulmonary infection, right pleural thickening, and pleural effusion . She completed the CT-guided pleural biopsy and postoperative histopathology revealed the tumor consisting of squamous cells were arranged in the nest bulk with invasive growth . Immunohistochemical (IHC) staining was performed for pleural lesion was positive for P63 , P40 , CK5/6 , epithelial membrane antigen (EMA) and negative for CD5 , CD117 and Calretinin . Combining with the IHC analysis, the pathological diagnosis was squamous cell carcinoma. Based on her medical history and results of histopathological examination and imaging, the patient was finally diagnosed with PPSCC.\nBetween 1977 and 2019, we identified 9 previous reports of squamous cell carcinoma arising from the pleura in patients. As described in Table , patients ranged in age between 49 and 75. These cases underwent chest pain, cough, dyspnoea, and other clinical symptoms. Most lesions of these patients were observed in the right pleura. Most of the cases had been in long standing chronic empyema, bronchopleural fistula or pneumothorax before a diagnosis of squamous cell carcinoma. But in our case, the patient was previously healthy without chronic empyema or bronchopleural fistula. After being diagnosed with pulmonary embolism, our patient experienced recurrent chest wall pain and pulmonary embolism.", + "fulltext_subclaims": [ + "In June 2017, a 49-year-old Chinese woman was admitted to the emergency department of the Northern Jiangsu People’s Hospital owing to chest tightness and breathing difficulty that persisted for 3 days.", + "She was previously in good health and was a non-smoker.", + "She had fever, chills, and a maximum body temperature of 38 °C.", + "She did not have urinary or fecal incontinence, chest pain, general fatigue, cough, or hemoptysis during the course of her disease.", + "White blood cell count was 12.21 × 109 cells/L.", + "The percentage of large white blood cells was 85.5%.", + "Blood gas analysis results showed 7.480 PH, 100 mmHg PaO2, 31 mmHg PaCO2, and 23.1 mmol/L HCO3−.", + "D-dimer assay indicated a value of 5.28 mg/L.", + "A computed tomography pulmonary angiography (CTPA) revealed filling defects in the main pulmonary artery, upper and lower pulmonary artery branch.", + "There were no distinct signs of embolism in color ultrasonography examination of the upper and lower limbs.", + "The patient was diagnosed with PE.", + "The patient was treated with anticoagulation, antiplatelet aggregation, and anti-infection medications.", + "During the 18 h after admission, the patient experienced worsening shortness of breath and anoxia.", + "The patient was subsequently transferred to the Emergency Intensive Care Unit (EICU) for non-invasive ventilator assisted ventilation.", + "The patient was intravenously administered alteplase once every 12 h for 3 consecutive days.", + "5000 units subcutaneous unfractionated heparin were administered.", + "Warfarin (5 mg) was orally administered once a day.", + "Once the prothrombin time (PT) and international normalized ratio (INR) were 2–2.5 times their respective normal levels, warfarin therapy was singly administered.", + "Once her condition had considerably improved and the anoxia was reduced, she was discharged from the hospital.", + "After 10 days, dyspnea and chest tightness recurred.", + "She experienced persistent right chest pain, which aggravated when she lied on her right side and was not relieved by rest.", + "Minor vaginal bleeding was also observed.", + "A CTPA revealed filling defects in the left and right branches of pulmonary artery as well as bilateral pleural effusion.", + "A routine coagulation test revealed 37 s PT and 3.33 INR.", + "A D-dimer assay showed a value of 8.75 mg/L.", + "No abnormalities were observed in limb color ultrasonography.", + "No abnormalities were observed in tumor antigen testing.", + "No abnormalities were observed in surrogate markers of autoimmune diseases.", + "We decided to discontinue warfarin to prevent an overdose situation.", + "Relevant contraindications were excluded.", + "The patient underwent interventional inferior vena cava filter implantation combined with thrombolysis implantation therapy.", + "The patient received low-dose urokinase.", + "Following surgery, she continued to receive anticoagulant treatment.", + "Once her condition had considerably improved, she was discharged.", + "One month later, she was referred to our hospital again due to swelling in her right lower limb.", + "She received interventional inferior right iliac vein dilation and stent placement.", + "In October 2018, she presented again with a week-long history of right-sided chest pain, cough, difficulty in breathing, and weight loss.", + "A CTPA revealed no evident improvement of the thrombosis in the right and left main pulmonary artery.", + "A CTPA revealed progression of pneumonia.", + "A CTPA revealed a reduced right pleural effusion, compared with the previous CTPA.", + "Tumor antigen testing revealed an elevated Ca125 level of 69.16 U/ml.", + "Tumor antigen testing revealed an elevated Ca199 level of 30.22 U/ml.", + "She was treated with anticoagulation, anti-infection, supportive, and oxygen therapies.", + "We recommended her to undergo a positron emission tomography-computed tomography (PET-CT) test.", + "She refused the PET-CT test.", + "She was discharged from the hospital.", + "The PET-CT revealed diffuse heterogeneous thickening of the right pleura.", + "The PET-CT revealed substantially increased glucose metabolism.", + "The PET-CT revealed fluorodeoxyglucose (FDG) uptake on L5 vertebral body.", + "The PET-CT revealed striated soft tissue lesions along the right iliac vein.", + "The PET-CT revealed increased FDG uptake.", + "In November 2018, she was once again admitted to our hospital.", + "Results of enhanced chest CT scan revealed bilateral PE.", + "Results of enhanced chest CT scan revealed bilateral pulmonary infection.", + "Results of enhanced chest CT scan revealed right pleural thickening.", + "Results of enhanced chest CT scan revealed pleural effusion.", + "She completed the CT-guided pleural biopsy.", + "Postoperative histopathology revealed the tumor consisting of squamous cells were arranged in the nest bulk with invasive growth.", + "Immunohistochemical (IHC) staining was performed for pleural lesion.", + "IHC staining was positive for P63.", + "IHC staining was positive for P40.", + "IHC staining was positive for CK5/6.", + "IHC staining was positive for epithelial membrane antigen (EMA).", + "IHC staining was negative for CD5.", + "IHC staining was negative for CD117.", + "IHC staining was negative for Calretinin.", + "Combining with the IHC analysis, the pathological diagnosis was squamous cell carcinoma.", + "Based on her medical history and results of histopathological examination and imaging, the patient was finally diagnosed with PPSCC.", + "Between 1977 and 2019, we identified 9 previous reports of squamous cell carcinoma arising from the pleura in patients.", + "Patients ranged in age between 49 and 75.", + "These cases underwent chest pain, cough, dyspnoea, and other clinical symptoms.", + "Most lesions of these patients were observed in the right pleura.", + "Most of the cases had been in long standing chronic empyema, bronchopleural fistula or pneumothorax before a diagnosis of squamous cell carcinoma.", + "In our case, the patient was previously healthy without chronic empyema or bronchopleural fistula.", + "After being diagnosed with pulmonary embolism, our patient experienced recurrent chest wall pain and pulmonary embolism." + ], + "summary": "A previously healthy 49-year-old female patient was admitted to Northern Jiangsu People's Hospital owing to chest tightness, cough, and breathing difficulty that persisted for 3 days. Following admission, a computed tomography (CT) pulmonary angiography revealed an embolism in the main pulmonary artery, upper and lower pulmonary artery branch. The patient was treated with alteplase, warfarin, and antibiotics. Over the following year, she experienced recurrent chest pain and tightness and breathing difficulty, with multiple CT pulmonary angiography revealing thrombosis in the right and left main pulmonary artery. No abnormalities were observed in surrogate markers of autoimmune diseases, tumor antigen testing, or ultrasonography; thus, the cause of recurrent PE was not identified. Subsequently, a positron emission tomography-computed tomography (PET-CT) examination revealed diffuse heterogeneous thickening of the right pleura and substantially increased glucose metabolism. A CT-guided pleural biopsy was performed, and histopathological examination of the pleura eventually revealed a diagnosis of PPSCC.", + "summary_subclaims": [ + "The patient was a 49-year-old female.", + "The patient was admitted to Northern Jiangsu People's Hospital.", + "The patient had chest tightness, cough, and breathing difficulty for 3 days.", + "A CT pulmonary angiography revealed an embolism in the main pulmonary artery.", + "A CT pulmonary angiography revealed an embolism in the upper pulmonary artery branch.", + "A CT pulmonary angiography revealed an embolism in the lower pulmonary artery branch.", + "The patient was treated with alteplase.", + "The patient was treated with warfarin.", + "The patient was treated with antibiotics.", + "Over the following year, she experienced recurrent chest pain.", + "Over the following year, she experienced recurrent chest tightness.", + "Over the following year, she experienced recurrent breathing difficulty.", + "Multiple CT pulmonary angiography revealed thrombosis in the right main pulmonary artery.", + "Multiple CT pulmonary angiography revealed thrombosis in the left main pulmonary artery.", + "No abnormalities were observed in surrogate markers of autoimmune diseases.", + "No abnormalities were observed in tumor antigen testing.", + "No abnormalities were observed in ultrasonography.", + "The cause of recurrent PE was not identified.", + "A PET-CT examination revealed diffuse heterogeneous thickening of the right pleura.", + "A PET-CT examination revealed substantially increased glucose metabolism.", + "A CT-guided pleural biopsy was performed.", + "Histopathological examination of the pleura revealed a diagnosis of PPSCC." + ] + }, + { + "id": "multiclinsum_test_410_en.txt", + "fulltext": "The patient was a 53-year-old man who had a history of testicular seminoma that was removed twice, at the ages of 41 and 48 years. The patient had been experiencing disorientation and difficulty in thinking for 1 month before the visit. His Karnofsky Performance Status (KPS) at the time of the first visit was 80. Contrast-enhanced magnetic resonance imaging (MRI) showed a markedly contrast-enhanced mass in the dorsal midbrain and obstructive hydrocephalus . Systemic examination, including whole-body, contrast-enhanced computed tomography, showed no obvious abnormalities. Blood samples showed a high serum soluble interleukin-2 receptor level of 624 U/ml. In addition, α-fetoprotein (3.1 ng/mL) and human chorionic gonadotropin (0.2 mIU/mL) were within normal limits. Neoplastic diseases such as PCNSL, tectal glioma, or intracranial metastasis of seminoma were considered in the differential diagnosis, and endoscopic tumor biopsy was performed with endoscopic third ventriculostomy (ETV). The patient was placed in a supine position under general anesthesia. The burr hole was located 11 cm from the nasion and 2 cm to the right of the midline. A Neuroport mini (Hakko Co., Nagano, Japan) was inserted into the anterior horn, and observation using a flexible endoscope (VEF-V, Olympus, Tokyo, Japan) showed that the aqueduct was stenotic due to the tumor, and the posterior part of the aqueduct was swollen [-]. A biopsy of the swollen area was performed. The lesion was pale pink, soft, and had minimal bleeding after the biopsy. After thorough intraventricular lavage to prevent dissemination, a third ventriculostomy was performed using an expanding balloon catheter (Expander Balloon Catheter SI Fuji Systems, Tokyo, Japan) . Intraoperative cerebrospinal fluid cytology showed a small number of atypical cells with bifurcated nuclear irregularities. Immunohistochemical study of the specimen showed that the tumor cells were CD3 negative, CD20 positive, and CD79a positive, indicating that the tumor was B-cell lymphoma. The final histopathological diagnosis of the tumor was diffuse large B-cell lymphoma . The patient’s postoperative course was uneventful and no new neurological deficit occurred. He underwent three courses of high-dose methotrexate (3.5 mg/m2) and whole-brain irradiation (30 Gy in 15 fractions). His KPS was 100 when he was discharged home.", + "fulltext_subclaims": [ + "The patient was a 53-year-old man.", + "The patient had a history of testicular seminoma that was removed twice.", + "The patient had been experiencing disorientation and difficulty in thinking for 1 month before the visit.", + "Contrast-enhanced magnetic resonance imaging showed a markedly contrast-enhanced mass in the dorsal midbrain.", + "Systemic examination showed no obvious abnormalities.", + "Blood samples showed a high serum soluble interleukin-2 receptor level of 624 U/ml.", + "α-fetoprotein was within normal limits.", + "Human chorionic gonadotropin was within normal limits.", + "Neoplastic diseases such as PCNSL, tectal glioma, or intracranial metastasis of seminoma were considered in the differential diagnosis.", + "Endoscopic tumor biopsy was performed with endoscopic third ventriculostomy.", + "The burr hole was located 11 cm from the nasion and 2 cm to the right of the midline.", + "A Neuroport mini was inserted into the anterior horn.", + "The aqueduct was stenotic due to the tumor.", + "A biopsy of the swollen area was performed.", + "The lesion was pale pink, soft, and had minimal bleeding after the biopsy.", + "A third ventriculostomy was performed using an expanding balloon catheter.", + "Intraoperative cerebrospinal fluid cytology showed a small number of atypical cells with bifurcated nuclear irregularities.", + "The tumor cells were CD3 negative.", + "The tumor cells were CD20 positive.", + "The tumor cells were CD79a positive.", + "The final histopathological diagnosis of the tumor was diffuse large B-cell lymphoma.", + "The patient underwent three courses of high-dose methotrexate.", + "The patient underwent whole-brain irradiation.", + "The patient’s KPS was 100 when he was discharged home." + ], + "summary": "The patient was referred to our hospital with a 1-month history of disorientation and magnetic resonance imaging showed hydrocephalus with an enhancing lesion in the tectum. Preoperative blood tests showed a high serum soluble interleukin-2 receptor level of 624 U/ml. Through a single burr hole, endoscopic third ventriculostomy and biopsy of the lesion were simultaneously performed with a flexible endoscope. The histological examination confirmed diffuse large B-cell lymphoma. The patient underwent chemotherapy and radiotherapy.", + "summary_subclaims": [ + "The patient was referred to our hospital with a 1-month history of disorientation.", + "Magnetic resonance imaging showed hydrocephalus.", + "Magnetic resonance imaging showed an enhancing lesion in the tectum.", + "Preoperative blood tests showed a high serum soluble interleukin-2 receptor level of 624 U/ml.", + "Through a single burr hole, endoscopic third ventriculostomy and biopsy of the lesion were simultaneously performed with a flexible endoscope.", + "The histological examination confirmed diffuse large B-cell lymphoma.", + "The patient underwent chemotherapy.", + "The patient underwent radiotherapy." + ] + }, + { + "id": "multiclinsum_test_190_en.txt", + "fulltext": "Ms XF is a 31 year old Caucasian female who has a diagnosis of uncontrolled asthma which has required repeated admissions over approximately ten years . She is otherwise well with no significant co-morbidities.\nHer usual medications are inhaled Salbutamol, Fluticasone accuhaler, nebulised Salbutamol, Salmeterol, Monteleucast 10 mg, Theophylline 300 mg bd, Vitamin D3 and Lansoprazole.\nThe patient was admitted with a history of cough with green sputum, wheezing and shortness of breath over three days. Initially she treated herself with Salbutamol inhalers and nebulised bronchodilators without improvement. She continued to deteriorate and in A&E she was treated with \"back to back\" salbutamol nebulisers and transferred to ITU. On admission she had no evidence of hypoxia, infection and hypovolemia as evidenced by clinical examination along with invasive monitoring and investigations such as blood gases, FBC, CRP, and CXR.\nIn ITU she complained of worsening breathlessness, despite an objective improvement in peak expiratory flow rate and wheeze. Her arterial blood gases at that time showed a compensated metabolic acidosis with high lactate. We excluded all common causes of a metabolic acidosis in this clinical setting including hypoxia, hypovolemia and sepsis. We suspected that the lactic acidosis may have been secondary to nebulised salbutamol, and consequently reduced the dosing interval. This resulted in a reduction in the serum lactic acid level. When the nebulised salbutamol was subsequently stopped the lactic acidosis promptly reversed . The patient was transferred to the ward and discharged home uneventfully.\nIn this particular patient, salbutamol and its resultant metabolic acidosis caused us difficulty in assessment and management of her asthma.", + "fulltext_subclaims": [ + "The patient is a 31 year old Caucasian female.", + "She has a diagnosis of uncontrolled asthma.", + "She has required repeated admissions over approximately ten years.", + "She is otherwise well with no significant co-morbidities.", + "Her usual medications include inhaled Salbutamol.", + "Her usual medications include Fluticasone accuhaler.", + "Her usual medications include nebulised Salbutamol.", + "Her usual medications include Salmeterol.", + "Her usual medications include Monteleucast 10 mg.", + "Her usual medications include Theophylline 300 mg bd.", + "Her usual medications include Vitamin D3.", + "Her usual medications include Lansoprazole.", + "The patient was admitted with a history of cough with green sputum.", + "The patient was admitted with a history of wheezing.", + "The patient was admitted with a history of shortness of breath over three days.", + "Initially she treated herself with Salbutamol inhalers.", + "Initially she treated herself with nebulised bronchodilators.", + "She continued to deteriorate.", + "In A&E she was treated with back to back salbutamol nebulisers.", + "She was transferred to ITU.", + "On admission she had no evidence of hypoxia.", + "On admission she had no evidence of infection.", + "On admission she had no evidence of hypovolemia.", + "In ITU she complained of worsening breathlessness.", + "Her arterial blood gases showed a compensated metabolic acidosis with high lactate.", + "We excluded all common causes of a metabolic acidosis in this clinical setting.", + "We suspected that the lactic acidosis may have been secondary to nebulised salbutamol.", + "We reduced the dosing interval of nebulised salbutamol.", + "This resulted in a reduction in the serum lactic acid level.", + "When the nebulised salbutamol was subsequently stopped the lactic acidosis promptly reversed.", + "The patient was transferred to the ward.", + "The patient was discharged home uneventfully.", + "In this particular patient, salbutamol and its resultant metabolic acidosis caused us difficulty in assessment and management of her asthma." + ], + "summary": "We present a case of severe lactic acidosis in the presence of normal tissue perfusion and oxygenation in a 31-year-old patient with poorly-controlled asthma. Acidosis promptly reversed on discontinuation of inhaled beta-agonists.", + "summary_subclaims": [ + "The patient was a 31-year-old individual.", + "The patient had poorly-controlled asthma.", + "The patient experienced severe lactic acidosis.", + "Tissue perfusion was normal.", + "Oxygenation was normal.", + "Acidosis promptly reversed on discontinuation of inhaled beta-agonists." + ] + }, + { + "id": "multiclinsum_test_615_en.txt", + "fulltext": "A 44-year-old Asian male visited the emergency room with chief complaints of intraoral pain and dysphagia that had started on the same day. The patient had paranoid-type schizophrenia that began 10 years ago; he had been hospitalized and was being treated at another clinic, and was transferred to the emergency room by the medical staff after swallowing a toothbrush.At the time of admission, the patient’s mental status, including orientation, was alert, and other vital signs were stable as well. Physical examinations showed uvular lacerations and a foreign body that appeared to be a toothbrush in the posterior oropharyngeal wall. A plain radiograph of the paranasal sinuses confirmed the presence of a foreign body located in the nasal cavity and oropharynx . CT scan of the neck revealed a foreign body spanning from the left nasopharynx to the right hypopharynx, as well as a broad area of subcutaneous emphysema in the anterior and lateral cervical regions . As additional damage could occur if the foreign body removal process was delayed, an emergency surgery was attempted.\nAn intraoral approach employing nasotracheal tube insertion under general anesthesia was used. The exposed part of the toothbrush was cut with an electric surgical saw. Following the removal of the two separate parts, the uvular laceration was sutured and the surgery was completed .\nTo evaluate hypopharyngeal and esophageal damage, an esophagogram was obtained using a water-soluble contrast dye on the first postoperative day, and a small perforation in the hypopharyngeal region was identified. Accordingly, the patient received conservative therapy, including intravenous broad-range antibiotic administration and was placed on oral dietary restrictions. No specific findings or complications were detected via the esophagogram on the 10th postoperative day, and the patient was subsequently discharged and is currently being followed up .", + "fulltext_subclaims": [ + "The patient is a 44-year-old Asian male.", + "The patient visited the emergency room with intraoral pain and dysphagia that started on the same day.", + "The patient had paranoid-type schizophrenia that began 10 years ago.", + "The patient was transferred to the emergency room after swallowing a toothbrush.", + "At the time of admission, the patient’s mental status, including orientation, was alert.", + "Physical examinations showed uvular lacerations.", + "A plain radiograph of the paranasal sinuses confirmed the presence of a foreign body located in the nasal cavity and oropharynx.", + "A CT scan of the neck revealed a foreign body spanning from the left nasopharynx to the right hypopharynx.", + "An emergency surgery was attempted.", + "An intraoral approach employing nasotracheal tube insertion under general anesthesia was used.", + "The exposed part of the toothbrush was cut with an electric surgical saw.", + "The uvular laceration was sutured.", + "An esophagogram was obtained using a water-soluble contrast dye on the first postoperative day.", + "A small perforation in the hypopharyngeal region was identified.", + "The patient received intravenous broad-range antibiotic administration.", + "The patient was placed on oral dietary restrictions.", + "No specific findings or complications were detected via the esophagogram on the 10th postoperative day.", + "The patient was discharged." + ], + "summary": "A 44-year-old Asian male visited the emergency room with chief complaints of intraoral pain and dysphagia that had started on the same day. The patient had paranoid-type schizophrenia that began 10 years ago; he had been hospitalized and was being treated at another clinic, and was transferred to the emergency room by the medical staff after swallowing a toothbrush. We successfully removed a toothbrush located within the pharynx of a patient with a history of a psychologic disorder via surgery and conservative treatment.", + "summary_subclaims": [ + "The patient is a 44-year-old Asian male.", + "The patient visited the emergency room with chief complaints of intraoral pain and dysphagia.", + "The intraoral pain and dysphagia had started on the same day.", + "The patient had paranoid-type schizophrenia that began 10 years ago.", + "The patient had been hospitalized.", + "The patient was being treated at another clinic.", + "The patient was transferred to the emergency room by the medical staff after swallowing a toothbrush.", + "A toothbrush was located within the pharynx.", + "The patient has a history of a psychologic disorder.", + "The toothbrush was removed via surgery and conservative treatment." + ] + }, + { + "id": "multiclinsum_test_2346_en.txt", + "fulltext": "A 51-year-old man was admitted to our hospital because of a two-year history of repeated episodes of epigastric pain and fullness without any obvious causes.\nTwo years ago, the patient began to present recurrent upper abdominal pain. The recurrent episodes of pain lasted approximately 1 h and were associated with nausea.\nThe patient denied any past surgical interventions.\nInitial evaluation in the hospital showed no remarkable clinical examination findings.\nLaboratory test results were within normal limits.\nAn abdominal ultrasound showed a large cystic lesion in the upper left quadrant abdomen, which was initially thought to be retroperitoneal . No significant vascular flow was seen on Doppler .\nA contrast-enhanced abdominal computed tomography (CT) scan was performed for further evaluation . The scan showed a large cystic hypodense lesion, measuring 95 mm × 61 mm × 66 mm, between the spleen and stomach, which was anterior to the left renal fascia and in close proximity to lateral limb of the left adrenal gland. The lesion was lobulated and well-circumscribed with a small amount of wall calcification.\nA cystic lymphangioma was the primary diagnostic consideration prior to pathological confirmation according to the imaging examination.", + "fulltext_subclaims": [ + "The patient is a 51-year-old man.", + "He was admitted to our hospital because of a two-year history of repeated episodes of epigastric pain and fullness without any obvious causes.", + "Two years ago, the patient began to present recurrent upper abdominal pain.", + "The recurrent episodes of pain lasted approximately 1 h and were associated with nausea.", + "The patient denied any past surgical interventions.", + "Initial evaluation in the hospital showed no remarkable clinical examination findings.", + "Laboratory test results were within normal limits.", + "An abdominal ultrasound showed a large cystic lesion in the upper left quadrant abdomen.", + "The lesion was initially thought to be retroperitoneal.", + "No significant vascular flow was seen on Doppler.", + "A contrast-enhanced abdominal computed tomography (CT) scan was performed for further evaluation.", + "The scan showed a large cystic hypodense lesion, measuring 95 mm × 61 mm × 66 mm, between the spleen and stomach.", + "The lesion was anterior to the left renal fascia.", + "The lesion was in close proximity to the lateral limb of the left adrenal gland.", + "The lesion was lobulated and well-circumscribed.", + "The lesion had a small amount of wall calcification.", + "A cystic lymphangioma was the primary diagnostic consideration prior to pathological confirmation according to the imaging examination." + ], + "summary": "A 51-year-old man presented with recurrent epigastric pain and fullness for two years. No significant findings were noted during physical examination and routine blood tests were unremarkable. An abdominal ultrasound revealed a large cyst in the upper left abdominal quadrant. A following contrast-enhanced abdominal computed tomography (CT) scan demonstrated a hypodense cystic lesion between the spleen and stomach. The lesion had scattered calcification in the cyst wall without any significant enhancement. The lesion was initially thought to be a cystic lymphangioma. The patient underwent a surgical resection and intraoperatively it was noted that the lesion was closely adherent to the greater curvature of the stomach. Subsequently, a resection of the gastric mass along with a partial gastrectomy was performed. The patient recovered quickly with a complete symptomatic relief and did not show any further complications during the 8-month follow-up.", + "summary_subclaims": [ + "The patient is a 51-year-old man.", + "The patient had recurrent epigastric pain and fullness for two years.", + "No significant findings were noted during physical examination.", + "Routine blood tests were unremarkable.", + "An abdominal ultrasound revealed a large cyst in the upper left abdominal quadrant.", + "A contrast-enhanced abdominal CT scan demonstrated a hypodense cystic lesion between the spleen and stomach.", + "The lesion had scattered calcification in the cyst wall.", + "The lesion had no significant enhancement.", + "The lesion was initially thought to be a cystic lymphangioma.", + "The patient underwent a surgical resection.", + "Intraoperatively, the lesion was noted to be closely adherent to the greater curvature of the stomach.", + "A resection of the gastric mass along with a partial gastrectomy was performed.", + "The patient recovered quickly.", + "The patient had complete symptomatic relief.", + "The patient did not show any further complications during the 8-month follow-up." + ] + }, + { + "id": "multiclinsum_test_144_en.txt", + "fulltext": "A 24-year-old man presented at the eye casualty of our clinic, with a 20-day history of severe pain, redness, photophobia, and tearing in both of his eyes. He had been treated repeatedly with corticosteroids and prophylactic topical antibiotics for bilateral viral conjunctivitis. His medical history revealed only congenital hepatitis B that was well under control. There was no ocular history of trauma, surgery, infection, or allergic/atopic episodes prior to this incidence, although minor trauma caused by eye rubbing remained a possibility.\nUpon ophthalmic assessment, the patient's visual acuity was 3/10 in both eyes. Slit-lamp examination revealed acute conjunctival hyperemia and inflammation, bilateral superior corneal perforation, and peripheral subepithelial and stromal neovascularization extending to the margins of the perforation and causing sizable iris prolapse was also noted. Both anterior chambers were shallow [Figures and ]. The crystalline lenses were clear and fundoscopy was normal bilaterally.\nThe patient underwent physical examination followed by laboratory work-up, including complete and differential blood cell counts, platelet counts, erythrocyte sedimentation rate, and liver and renal function tests. Because his condition was rather suspicious, immunological testing was ordered, including rheumatoid factor (RF), antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies, and C-reactive protein (CRP) titers. The patient was also subjected to a fluorescent treponemal antibody absorption test, Mantoux test, chest X-ray, and a complete work-up for sexually transmitted diseases.\nThe laboratory work-up revealed only lymphocytosis, and this prompted a work-up for systemic HSV infection, whereby paired samples were subjected to serological evaluation with IgG and IgM. A high IgM HSV-1 titer was found, with no IgG HSV-1 titer. Cultures of corneal and conjunctival scrapings were negative for bacteria or fungi, and specimens of corneal scrapings from both eyes were sent for HSV gene detection by polymerase chain reaction (PCR). Intravenous acyclovir treatment (250 mg, twice daily) was commenced, and topical medication was applied, namely acyclovir, prednisone, prophylactic antibiotics, and cyclopentolate.\nAfter 2 weeks of intravenous and topical acyclovir treatment, the patient's clinical status had improved greatly; his symptoms subsided, and little inflammation was noted in either eye. Positive PCR analysis for the HSV genome verified the diagnosis of bilateral HSV-related PUK.\nBecause the patient's condition was urgent, an aggressive surgical approach was adopted. In his right eye, a corneal and conjunctival resection of 2 clock hours was performed on both sides of the corneal ulcer, removing redundant, protruding, epithelialized iris tissue. Iridoplasty and eccentric penetrating keratoplasty were then performed after two weeks of intravenous and topical acyclovir treatment . The left eye was managed in two steps. During the first surgical procedure, the same steps were taken as in his right eye, but instead of an eccentric penetrating keratoplasty, two temporary tectonic corneal grafts were used—a nasal and a temporal—and an amniotic membrane was transplanted . A corneal melt developed 1 month later in the temporal patch graft, so a large diameter penetrating keratoplasty was performed .\nHistological analysis of the resected tissue showed a cellular population consisting of lymphocytes, macrophages, fibroblasts, and mast cells. Neovascular capillaries were also observed.\nTwelve months after surgery, the HSV keratitis had not recurred.", + "fulltext_subclaims": [ + "The patient was a 24-year-old man.", + "He had a 20-day history of severe pain, redness, photophobia, and tearing in both eyes.", + "He had been treated repeatedly with corticosteroids and prophylactic topical antibiotics.", + "The treatment was for bilateral viral conjunctivitis.", + "His medical history revealed congenital hepatitis B that was well under control.", + "There was no ocular history of trauma, surgery, infection, or allergic/atopic episodes prior to this incidence.", + "Minor trauma caused by eye rubbing remained a possibility.", + "The patient's visual acuity was 3/10 in both eyes.", + "Slit-lamp examination revealed acute conjunctival hyperemia and inflammation.", + "Bilateral superior corneal perforation was noted.", + "Peripheral subepithelial and stromal neovascularization extending to the margins of the perforation was also noted.", + "Sizable iris prolapse was noted.", + "Both anterior chambers were shallow.", + "The crystalline lenses were clear.", + "Fundoscopy was normal bilaterally.", + "The patient underwent physical examination.", + "The patient underwent laboratory work-up, including complete and differential blood cell counts, platelet counts, erythrocyte sedimentation rate, and liver and renal function tests.", + "Immunological testing was ordered, including rheumatoid factor, antinuclear antibodies, antineutrophil cytoplasmic antibodies, and C-reactive protein titers.", + "The patient was subjected to a fluorescent treponemal antibody absorption test.", + "The patient was subjected to a Mantoux test.", + "The patient was subjected to a chest X-ray.", + "A complete work-up for sexually transmitted diseases was performed.", + "The laboratory work-up revealed only lymphocytosis.", + "A work-up for systemic HSV infection was prompted.", + "Paired samples were subjected to serological evaluation with IgG and IgM.", + "A high IgM HSV-1 titer was found.", + "There was no IgG HSV-1 titer.", + "Cultures of corneal and conjunctival scrapings were negative for bacteria or fungi.", + "Specimens of corneal scrapings from both eyes were sent for HSV gene detection by polymerase chain reaction.", + "Intravenous acyclovir treatment (250 mg, twice daily) was commenced.", + "Topical medication was applied, namely acyclovir, prednisone, prophylactic antibiotics, and cyclopentolate.", + "After 2 weeks of intravenous and topical acyclovir treatment, the patient's clinical status had improved greatly.", + "His symptoms subsided.", + "Little inflammation was noted in either eye.", + "Positive PCR analysis for the HSV genome verified the diagnosis of bilateral HSV-related PUK.", + "An aggressive surgical approach was adopted.", + "In his right eye, a corneal and conjunctival resection of 2 clock hours was performed on both sides of the corneal ulcer.", + "Redundant, protruding, epithelialized iris tissue was removed.", + "Iridoplasty and eccentric penetrating keratoplasty were performed after two weeks of intravenous and topical acyclovir treatment.", + "The left eye was managed in two steps.", + "During the first surgical procedure, the same steps were taken as in his right eye.", + "Instead of an eccentric penetrating keratoplasty, two temporary tectonic corneal grafts were used—a nasal and a temporal—and an amniotic membrane was transplanted.", + "A corneal melt developed 1 month later in the temporal patch graft.", + "A large diameter penetrating keratoplasty was performed.", + "Histological analysis of the resected tissue showed a cellular population consisting of lymphocytes, macrophages, fibroblasts, and mast cells.", + "Neovascular capillaries were also observed.", + "Twelve months after surgery, the HSV keratitis had not recurred." + ], + "summary": "A 24-year-old man presented at the eye casualty of our clinic, with a 20-day history of severe pain, redness, photophobia, and tearing in both of his eyes. Slit-lamp examination revealed bilateral superior corneal perforation. A laboratory work-up that included immunological testing for infectious and autoimmune factors showed primary HSV infection. Positive PCR analysis of corneal scrapings for HSV confirmed initial end-organ ocular infection. Because the patient showed progressive HSV-1-related PUK resulting in bilateral superior corneal perforation with iris prolapse, he was prescribed both systemic and topical acyclovir and prednisone. He then underwent bilateral surgical intervention, namely eccentric penetrating keratoplasty in one eye and a two step procedure in the other, whereby two corneal patch grafts and an amniotic membrane transplant were initially used, followed 1 month later by a large diameter penetrating keratoplasty.", + "summary_subclaims": [ + "A 24-year-old man presented at the eye casualty of our clinic.", + "He had a 20-day history of severe pain, redness, photophobia, and tearing in both of his eyes.", + "Slit-lamp examination revealed bilateral superior corneal perforation.", + "A laboratory work-up that included immunological testing for infectious and autoimmune factors showed primary HSV infection.", + "Positive PCR analysis of corneal scrapings for HSV confirmed initial end-organ ocular infection.", + "The patient showed progressive HSV-1-related PUK resulting in bilateral superior corneal perforation with iris prolapse.", + "He was prescribed both systemic and topical acyclovir and prednisone.", + "He underwent bilateral surgical intervention.", + "He underwent eccentric penetrating keratoplasty in one eye.", + "He underwent a two step procedure in the other eye.", + "Two corneal patch grafts and an amniotic membrane transplant were initially used.", + "A large diameter penetrating keratoplasty was performed 1 month later." + ] + }, + { + "id": "multiclinsum_test_3198_en.txt", + "fulltext": "A 21-year-old girl complaining of a six-month history of progressive dyspnoea and chest pain was transferred to our centre because of heart failure, without a history of any cardiovascular diseases, injuries or operations.\n\nOn examination, there was a grade 3/6 continuous machinery murmur that was maximal between the right 2nd and 3rd intercostal region and radiated to the right infraclavicular fossa. The patient had a normal saturation value at rest in ambient air (SPO2 95%) with non-cyanotic skin colour. Chest-X-ray revealed cardiomegaly. The electrocardiogram showed sinus rhythm with a heart rate of 95 bpm and a complete right bundle branch block and right ventricular hypertrophy. The respiratory tests were not abnormal.\n\nTransthoracic echocardiography showed a dilated right subclavian artery with an 8-mm fistula to the SVC and obvious stenosis at the proximal initial site of the fistula, in addition to a markedly dilated right ventricle and right atrium and mild tricuspid regurgitation. Continuous wave Doppler showed a flow signal at 2.3 m/s that was continuously moving from the RSA to the SVC with a gradient of 22 mmHg, while the highest flow rate was 3.9 m/s at the stenosis site of the fistula with a gradient of 59 mmHg. Computed tomography angiography further delineated the anatomy of the arteriovenous fistula from the RSA to the SVC and stenosis of the fistula.\n\nThe patient underwent transcatheter occlusion for the fistula under local anaesthesia. Briefly, a 10/12 mm Amplatzer ductal occluder was delivered and deployed from the SVC side using a 5-F H1 catheter by angiogram guidance, and an 8F sheath was used to send the occluder to occlude the abnormal fistulous connection. The post-procedure angiogram revealed a completely occluded lumen of the fistula, and the echocardiogram showed no residual shunt. The patient had an uneventful course and a significant improvement in symptoms at the 3-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 21-year-old girl.", + "She had a six-month history of progressive dyspnoea.", + "She had a six-month history of chest pain.", + "She was transferred to the centre because of heart failure.", + "She had no history of any cardiovascular diseases.", + "She had no history of injuries.", + "She had no history of operations.", + "On examination, there was a grade 3/6 continuous machinery murmur.", + "The murmur was maximal between the right 2nd and 3rd intercostal region.", + "The murmur radiated to the right infraclavicular fossa.", + "The patient had a normal saturation value at rest in ambient air (SPO2 95%).", + "The patient had a non-cyanotic skin colour.", + "Chest-X-ray revealed cardiomegaly.", + "The electrocardiogram showed sinus rhythm.", + "The electrocardiogram showed a heart rate of 95 bpm.", + "The electrocardiogram showed a complete right bundle branch block.", + "The electrocardiogram showed right ventricular hypertrophy.", + "The respiratory tests were not abnormal.", + "Transthoracic echocardiography showed a dilated right subclavian artery.", + "Transthoracic echocardiography showed an 8-mm fistula to the SVC.", + "Transthoracic echocardiography showed stenosis at the proximal initial site of the fistula.", + "Transthoracic echocardiography showed a markedly dilated right ventricle.", + "Transthoracic echocardiography showed a markedly dilated right atrium.", + "Transthoracic echocardiography showed mild tricuspid regurgitation.", + "Continuous wave Doppler showed a flow signal at 2.3 m/s from the RSA to the SVC.", + "The flow signal had a gradient of 22 mmHg.", + "The highest flow rate was 3.9 m/s at the stenosis site of the fistula.", + "The highest flow rate had a gradient of 59 mmHg.", + "Computed tomography angiography further delineated the anatomy of the arteriovenous fistula.", + "Computed tomography angiography showed stenosis of the fistula.", + "The patient underwent transcatheter occlusion for the fistula under local anaesthesia.", + "A 10/12 mm Amplatzer ductal occluder was delivered and deployed from the SVC side.", + "A 5-F H1 catheter was used to deliver the occluder.", + "An 8F sheath was used to send the occluder.", + "The post-procedure angiogram revealed a completely occluded lumen of the fistula.", + "The post-procedure echocardiogram showed no residual shunt.", + "The patient had an uneventful course.", + "The patient had a significant improvement in symptoms at the 3-month follow-up." + ], + "summary": "We present an unusual case of a 21-year-old female suffering from new-onset heart failure at 20 years old who was diagnosed with a congenital arteriovenous fistula from the right subclavian artery to the superior vena cava (RSA-to-SVC) with stenosis at the proximal initial site of the fistula. The patient successfully underwent transcatheter occlusion for the fistula and had a significant improvement in symptoms at the 3-month follow-up.", + "summary_subclaims": [ + "The patient is a 21-year-old female.", + "She had new-onset heart failure at 20 years old.", + "She was diagnosed with a congenital arteriovenous fistula from the right subclavian artery to the superior vena cava.", + "The fistula had stenosis at the proximal initial site.", + "The patient underwent transcatheter occlusion for the fistula.", + "She had a significant improvement in symptoms at the 3-month follow-up." + ] + }, + { + "id": "multiclinsum_test_1890_en.txt", + "fulltext": "A 48-year-old woman (height 165 cm, weight 67 kg) had been hospitalized for schizophrenia in a psychiatric hospital. She had been prescribed sultopride hydrochloride, risperidone, and zotepine. Seven months prior to surgery, she was found to have developed dyspnea and palpitation on exertion, and lower leg edema. Computed tomography (CT) revealed thrombi in the main trunk of the left pulmonary artery as well as in the peripheries of the bilateral pulmonary arteries, confirming the diagnosis of pulmonary embolism. Transthoracic echocardiography showed a dilated right ventricle (RV) with moderate tricuspid valve regurgitation (TR) and an estimated mPAP of 43 mmHg, indicating PH . Anticoagulant therapy was started with apixaban.\nFive months prior to surgery, anticoagulant therapy was discontinued because of irregular genital bleeding, but it was resumed 2 weeks subsequently because of the reappearance of pulmonary embolism symptoms. Six weeks prior to surgery, anticoagulant therapy was again temporarily discontinued as a result of increased genital bleeding. She was diagnosed with endometrial cancer, and total hysterectomy was scheduled.\nTwo weeks prior to surgery, she was transferred to our institution from the psychiatric hospital. Her vital parameters at admission were as follows: heart rate of 72 beats/min, blood pressure of 124/86 mmHg, and percutaneous oxygen saturation (SpO2) of 92% under oxygen administration of 2 L/min. She had severe edema of the lower extremities and jugular vein distention. Transthoracic echocardiography showed a dilated RV with flattening of the interventricular septum and with moderate TR, in addition to an estimated mPAP of 54 mmHg, suggesting severe PH . The left ventricle (LV) appeared D-shaped with preserved systolic function and exhibited an ejection fraction of 66%. Although CT showed no emboli in the pulmonary trunk , multiple blood flow defects revealed by lung perfusion scan suggested multiple emboli in the distal pulmonary artery , leading to the diagnosis of CTEPH, and promoted physicians to perform BPA in order to decrease mPAP before surgery.\nTwo BPA sessions were performed for bilateral pulmonary arteries by interventional cardiologists in another expert institution over a span of 6 days. The first BPA for A1, A2, A3, and A9 was performed, and the second BPA for A8b, A10a, and A10b was performed under local anesthesia. After BPA, SpO2 increased from 86 to 91%. Transthoracic echocardiography performed 2 days after the second BPA showed an improvement in the deformity of the LV and mild TR, and the estimated mPAP decreased to 33 mmHg . After the first BPA, warfarin was started and stopped the day before surgery, and preoperative bridging with heparin was initiated. We could not assess whether the subjective symptoms and exercise capacity of the patient improved after BPA, since she had stayed in bed all day because of depression in schizophrenia.\nTotal hysterectomy was performed 3 days after the second BPA. General anesthesia was selected because of the patient’s unstable mental status and perioperative anticoagulant therapy. Upon entering the operating room, her heart rate was 66 beats/min, blood pressure was 128/82 mmHg, and SpO2 was 92% under oxygen administration of 2 L/min. General anesthesia was induced using midazolam 3 mg, continuous infusion of remifentanil 0.1 μg/kg/min, and fentanyl 200 μg. After administration of rocuronium 40 mg, tracheal intubation was performed. Anesthesia was maintained using desflurane 3–4% in a 45% oxygen–air mixture with continuous infusion of remifentanil 0.1–0.2 μg/kg/min. A pulmonary artery catheter (PAC) was inserted in the right internal jugular vein. Transesophageal echocardiography (TEE) showed RV enlargement with mild TR and shape distortion of the interventricular septum during systole.\nIntroducer sheaths were placed in the right femoral artery and vein to allow for venoarterial extracorporeal membrane oxygenation in preparation for pulmonary hypertensive crisis. Hypoxia, hypercapnia, acidosis, hypothermia, and inadequate analgesia were avoided to prevent increase of pulmonary vascular resistance . At 10 min after hysterectomy, the patient’s blood pressure decreased to 58/35 mmHg, with a pulmonary artery pressure (PAP) of 28/19 mmHg. TEE indicated that there was no observable change in the size of the RV and LV cavity with mild TR; therefore, we determined that the patient was not in a pulmonary hypertensive crisis. The cause of the temporary hypotension was unclear; however, it was restored rapidly after administration of a total of 12 mg ephedrine. Thereafter, values ranged 90–120/50–60 mmHg for blood pressure, 30–40 mmHg for mPAP, and 1.9–2.4 L/min/m2 for cardiac index.\nNo vasopressor other than ephedrine was required. The operation time was 1 h and 36 min and blood loss was 88 g. Because of concerns about postoperative restlessness, the TEE probe, PAC, and introducer sheaths were removed before awakening. The patient was promptly awakened and the endotracheal tube was removed. Effective postoperative analgesia was achieved with intravenous patient-controlled analgesia using fentanyl. Postoperatively, the patient was managed in the general gynecology ward. On the fifth day after surgery, anticoagulant therapy was restarted with apixaban. Transthoracic echocardiography showed mild TR, with an estimated mPAP of 28 mmHg and no worsening of PH . The patient was transferred to the psychiatric hospital on the 19th day after surgery.", + "fulltext_subclaims": [ + "The patient was a 48-year-old woman.", + "She had been hospitalized for schizophrenia.", + "She had been prescribed sultopride hydrochloride.", + "She had been prescribed risperidone.", + "She had been prescribed zotepine.", + "Seven months prior to surgery, she was found to have developed dyspnea and palpitation on exertion.", + "Seven months prior to surgery, she had lower leg edema.", + "Computed tomography revealed thrombi in the main trunk of the left pulmonary artery.", + "Computed tomography revealed thrombi in the peripheries of the bilateral pulmonary arteries.", + "The diagnosis of pulmonary embolism was confirmed.", + "Transthoracic echocardiography showed a dilated right ventricle.", + "Transthoracic echocardiography showed moderate tricuspid valve regurgitation.", + "The estimated mean pulmonary artery pressure was 43 mmHg.", + "Anticoagulant therapy was started with apixaban.", + "Five months prior to surgery, anticoagulant therapy was discontinued because of irregular genital bleeding.", + "Anticoagulant therapy was resumed 2 weeks after discontinuation.", + "Anticoagulant therapy was again temporarily discontinued 6 weeks prior to surgery.", + "She was diagnosed with endometrial cancer.", + "Total hysterectomy was scheduled.", + "Two weeks prior to surgery, she was transferred to the current institution.", + "At admission, her heart rate was 72 beats/min.", + "At admission, her blood pressure was 124/86 mmHg.", + "At admission, her SpO2 was 92% under oxygen administration of 2 L/min.", + "She had severe edema of the lower extremities.", + "She had jugular vein distention.", + "Transthoracic echocardiography showed a dilated right ventricle.", + "Transthoracic echocardiography showed flattening of the interventricular septum.", + "Transthoracic echocardiography showed moderate tricuspid valve regurgitation.", + "The estimated mean pulmonary artery pressure was 54 mmHg.", + "The left ventricle appeared D-shaped.", + "The left ventricular ejection fraction was 66%.", + "Computed tomography showed no emboli in the pulmonary trunk.", + "A lung perfusion scan showed multiple blood flow defects.", + "The diagnosis of chronic thromboembolic pulmonary hypertension was made.", + "Balloon pulmonary angioplasty was planned.", + "Two balloon pulmonary angioplasty sessions were performed.", + "The first BPA was performed for A1, A2, A3, and A9.", + "The second BPA was performed for A8b, A10a, and A10b.", + "BPA was performed under local anesthesia.", + "After BPA, SpO2 increased from 86 to 91%.", + "Transthoracic echocardiography 2 days after the second BPA showed improvement in the deformity of the left ventricle.", + "Transthoracic echocardiography 2 days after the second BPA showed mild tricuspid valve regurgitation.", + "The estimated mean pulmonary artery pressure decreased to 33 mmHg.", + "Warfarin was started after the first BPA.", + "Warfarin was stopped the day before surgery.", + "Preoperative bridging with heparin was initiated.", + "Total hysterectomy was performed 3 days after the second BPA.", + "General anesthesia was selected.", + "General anesthesia was induced using midazolam 3 mg.", + "General anesthesia was induced using continuous infusion of remifentanil 0.1 μg/kg/min.", + "General anesthesia was induced using fentanyl 200 μg.", + "Rocuronium 40 mg was administered before tracheal intubation.", + "Anesthesia was maintained using desflurane 3–4% in a 45% oxygen–air mixture.", + "Anesthesia was maintained with continuous infusion of remifentanil 0.1–0.2 μg/kg/min.", + "A pulmonary artery catheter was inserted in the right internal jugular vein.", + "Transesophageal echocardiography showed right ventricular enlargement.", + "Transesophageal echocardiography showed mild tricuspid valve regurgitation.", + "Transesophageal echocardiography showed shape distortion of the interventricular septum during systole.", + "Introducer sheaths were placed in the right femoral artery and vein.", + "Hypoxia, hypercapnia, acidosis, hypothermia, and inadequate analgesia were avoided.", + "At 10 min after hysterectomy, blood pressure decreased to 58/35 mmHg.", + "At 10 min after hysterectomy, pulmonary artery pressure was 28/19 mmHg.", + "Transesophageal echocardiography indicated no observable change in the size of the right ventricle.", + "Transesophageal echocardiography indicated no observable change in the size of the left ventricle.", + "The patient was not in a pulmonary hypertensive crisis.", + "The cause of the temporary hypotension was unclear.", + "The hypotension was restored after administration of a total of 12 mg ephedrine.", + "No vasopressor other than ephedrine was required.", + "The operation time was 1 h and 36 min.", + "Blood loss was 88 g.", + "The TEE probe, PAC, and introducer sheaths were removed before awakening.", + "The patient was promptly awakened.", + "The endotracheal tube was removed.", + "Postoperative analgesia was achieved with intravenous patient-controlled analgesia using fentanyl.", + "The patient was managed in the general gynecology ward.", + "On the fifth day after surgery, anticoagulant therapy was restarted with apixaban.", + "Transthoracic echocardiography showed mild tricuspid valve regurgitation.", + "The estimated mean pulmonary artery pressure was 28 mmHg.", + "There was no worsening of pulmonary hypertension.", + "The patient was transferred to the psychiatric hospital on the 19th day after surgery." + ], + "summary": "A 48-year-old woman was transferred to our hospital to undergo total hysterectomy for endometrial cancer. She developed pulmonary embolism 7 months ago at another hospital, and a diagnosis of CTEPH was made based on multiple pulmonary emboli and pulmonary hypertension at our institute. Two BPA sessions for seven branches of the bilateral pulmonary arteries were conducted, resulting in a decrease of mean pulmonary artery pressure from 54 to 33 mmHg. Total hysterectomy was successfully performed under general anesthesia without any complications.", + "summary_subclaims": [ + "The patient is a 48-year-old woman.", + "She was transferred to undergo total hysterectomy for endometrial cancer.", + "She developed pulmonary embolism 7 months ago at another hospital.", + "A diagnosis of CTEPH was made based on multiple pulmonary emboli and pulmonary hypertension.", + "Two BPA sessions for seven branches of the bilateral pulmonary arteries were conducted.", + "The mean pulmonary artery pressure decreased from 54 to 33 mmHg.", + "Total hysterectomy was successfully performed under general anesthesia.", + "The hysterectomy was performed without any complications." + ] + }, + { + "id": "multiclinsum_test_1196_en.txt", + "fulltext": "A 9-year-old girl presented to our hospital emergency department with a 3-wk history of ineffective right limb movement.\nThe treatment timeline is shown in Figure . A head computed tomography (CT) scan revealed a quasi-circular mass in the left frontal-parietal region with high-density and associated hemorrhage . Brain magnetic resonance imaging (MRI) revealed low signals on T1 weighted imaging with high surrounding signals. High signals on T2 weighted imaging with low surrounding signals were observed, with marked enhancement on contrast measuring 4.8 cm × 5.0 cm × 4.5 cm in the left motor area of the frontal-parietal lobes . The imaging characteristics were similar to meningioma. An unenhanced chest CT scan revealed no nodules in the chest.\nLaboratory tests including complete blood cell counts, bleeding time, activated partial thromboplastin time, prothrombin time, liver and renal function and blood glucose level were within normal ranges.\nHer temperature was 36.6 ℃, resting respiratory rate was 16 breaths/min, heart rate was 90 bpm and blood pressure was 120/75 mmHg. Neurological examination showed that her Glasgow Coma Scale score was 15 (E4V5M6), and muscle strength was grade 2 in the right limbs. She did not have any other neurological deficits.\nShe had no personal or family history of benign or malignant tumors.\nThe patient had no history of prior illness.\nThe patient had ineffective right limb movement for 3 wk. She also had headaches, accompanied by nausea and vomiting and excess sleep. A head CT scan revealed a quasi-circular mass in the left frontal-parietal region with high-density and associated hemorrhage.", + "fulltext_subclaims": [ + "A 9-year-old girl presented to our hospital emergency department with a 3-wk history of ineffective right limb movement.", + "A head computed tomography (CT) scan revealed a quasi-circular mass in the left frontal-parietal region with high-density and associated hemorrhage.", + "Brain magnetic resonance imaging (MRI) revealed low signals on T1 weighted imaging with high surrounding signals.", + "High signals on T2 weighted imaging with low surrounding signals were observed.", + "Marked enhancement on contrast measuring 4.8 cm × 5.0 cm × 4.5 cm was observed in the left motor area of the frontal-parietal lobes.", + "The imaging characteristics were similar to meningioma.", + "An unenhanced chest CT scan revealed no nodules in the chest.", + "Laboratory tests including complete blood cell counts, bleeding time, activated partial thromboplastin time, prothrombin time, liver and renal function and blood glucose level were within normal ranges.", + "Her temperature was 36.6 ℃.", + "Her resting respiratory rate was 16 breaths/min.", + "Her heart rate was 90 bpm.", + "Her blood pressure was 120/75 mmHg.", + "Her Glasgow Coma Scale score was 15 (E4V5M6).", + "Muscle strength was grade 2 in the right limbs.", + "She did not have any other neurological deficits.", + "She had no personal or family history of benign or malignant tumors.", + "The patient had no history of prior illness.", + "She had ineffective right limb movement for 3 wk.", + "She also had headaches, accompanied by nausea and vomiting and excess sleep." + ], + "summary": "We present a rare case of SFT in a 9-year-old girl with a space-occupying effect in the frontal-parietal lobes. She underwent craniotomy, and the mass was resected. Immunohistochemistry examination of the specimen showed that Ki-67 proliferation index staining was highly positive in 80% of tumor cells. Whole exome sequencing of the surgical tissue showed 38 somatic gene mutations and 1 gene amplification such as fibroblast growth factor receptor 4 or TP53. At 1.5 mo after surgery, head magnetic resonance imaging revealed that the tumor had recurred. The patient received 60 Gy and 30 fractions of intensity modulated radiotherapy. The patient then received anlotinib 8 mg po qd for 1-14 d of a 21 d cycle. Following this regimen, the patient achieved stable disease for > 17 mo. Magnetic resonance imaging at 1.5 year after surgery showed that the tumor had not progressed.", + "summary_subclaims": [ + "The patient is a 9-year-old girl.", + "The patient had a space-occupying effect in the frontal-parietal lobes.", + "The patient underwent craniotomy.", + "The mass was resected.", + "Immunohistochemistry examination showed Ki-67 proliferation index staining was highly positive in 80% of tumor cells.", + "Whole exome sequencing showed 38 somatic gene mutations.", + "Whole exome sequencing showed 1 gene amplification.", + "The gene amplification included fibroblast growth factor receptor 4.", + "The gene amplification included TP53.", + "At 1.5 mo after surgery, head magnetic resonance imaging revealed that the tumor had recurred.", + "The patient received 60 Gy and 30 fractions of intensity modulated radiotherapy.", + "The patient received anlotinib 8 mg po qd for 1-14 d of a 21 d cycle.", + "Following this regimen, the patient achieved stable disease for > 17 mo.", + "Magnetic resonance imaging at 1.5 year after surgery showed that the tumor had not progressed." + ] + }, + { + "id": "multiclinsum_test_684_en.txt", + "fulltext": "A 64-year old man was referred to our department for right recurrent pleural effusion. A CT scan showed thickened right parietal pleura with a minimal pleural effusion, but no pulmonary nodules or lymphadenopathies or distant metastases. Because of negative cytology malignancy, the patient underwent a thoracoscopic pleural biopsy on December 2004 that showed an epithelioid monophasic pleural mesothelioma, followed by talc pleurodesis at the end of the procedure.\nThree weeks later the patient underwent a right extrapleural pneumonectomy with coverage of the bronchial stump with a flap of thymic tissue. The pathological examination confirmed a monophasic epithelioid pleural mesothelioma, with lung and pericardial fat infiltration, but no invasion of the diaphragm or pericardium (pT3 N0 M0). The postoperative period was uneventful.\nTen months later the patient complained of a fever and cough. The diagnosis of broncho-pleural fistula was made immediately after the first appearance of cough and fever by bronchoscopy that clearly showed a 2-mm fistula on the mediastinal side of the stump confirmed by the methilene blue passage from bronchus to the chest tube. Rapid fluid drainage and antibiotic therapy allowed us to cure the infection of the pleural space avoiding the formation of empyema. After chest tube drainage, the attempt to conservatively close the fistula using biological glue was unsuccessful. So we decided to use a modified Y Dumon stent (Tracheobronxane Y; Novatech SA, La Ciotat Cedex France) to exclude the right stump. The right arm of the Y was shortened and the open end was closed with a silicone material from which the stent was fabricated, and then inserted in the tracheobronchial tree trough a rigid bronchoscope. The tracheal part was 18 mm in width and 4 cm in length, while the left bronchial arm was 16 mm in width and 2 cm in length. Under rigid bronchoscopy, we first introduced the biological glue (CoSeal, Baxter Healthcare Corporation, Fremont, CA – USA) all over the bronchial stump that was of 1 cm lenght, followed by the insertion of the modified Y Dumon stent .\nThe negative cultures from the pleural fluid allowed us to remove the chest drain and to discharge the patient on the 3rd postoperative day. The patient was uneventful (no empyema or pneumonitis verified) until he died 4 months later for pulmonary emboli. The post-mortem examination showed a massive pulmonary thrombus in the left main pulmonary artery which explain the sudden respiratory insufficiency and death at home and an initial relapse of mesothelioma in the posterior part of chest wall, without signs of infections.", + "fulltext_subclaims": [ + "A 64-year old man was referred to our department for right recurrent pleural effusion.", + "A CT scan showed thickened right parietal pleura with a minimal pleural effusion.", + "The CT scan showed no pulmonary nodules.", + "The CT scan showed no lymphadenopathies.", + "The CT scan showed no distant metastases.", + "The patient underwent a thoracoscopic pleural biopsy on December 2004.", + "The thoracoscopic pleural biopsy showed an epithelioid monophasic pleural mesothelioma.", + "The patient underwent talc pleurodesis at the end of the thoracoscopic procedure.", + "Three weeks later the patient underwent a right extrapleural pneumonectomy.", + "The bronchial stump was covered with a flap of thymic tissue.", + "The pathological examination confirmed a monophasic epithelioid pleural mesothelioma.", + "The tumor showed lung and pericardial fat infiltration.", + "The tumor showed no invasion of the diaphragm.", + "The tumor showed no invasion of the pericardium.", + "The tumor stage was pT3 N0 M0.", + "The postoperative period was uneventful.", + "Ten months later the patient complained of a fever and cough.", + "The diagnosis of broncho-pleural fistula was made immediately after the first appearance of cough and fever.", + "Bronchoscopy showed a 2-mm fistula on the mediastinal side of the stump.", + "Methylene blue passage from bronchus to the chest tube confirmed the fistula.", + "Rapid fluid drainage and antibiotic therapy allowed us to cure the infection of the pleural space.", + "The attempt to conservatively close the fistula using biological glue was unsuccessful.", + "A modified Y Dumon stent was used to exclude the right stump.", + "The right arm of the Y was shortened.", + "The open end of the right arm was closed with a silicone material.", + "The stent was inserted in the tracheobronchial tree through a rigid bronchoscope.", + "The tracheal part of the stent was 18 mm in width and 4 cm in length.", + "The left bronchial arm of the stent was 16 mm in width and 2 cm in length.", + "Biological glue was introduced all over the bronchial stump.", + "The bronchial stump was 1 cm in length.", + "The negative cultures from the pleural fluid allowed us to remove the chest drain.", + "The patient was discharged on the 3rd postoperative day.", + "The patient was uneventful until he died 4 months later for pulmonary emboli.", + "The post-mortem examination showed a massive pulmonary thrombus in the left main pulmonary artery.", + "The post-mortem examination showed an initial relapse of mesothelioma in the posterior part of the chest wall.", + "The post-mortem examination showed no signs of infections." + ], + "summary": "We describe a case of late bronchopleural fistula after right extrapleural pneumonectomy for malignant mesothelioma. Bronchoscopic attempts to repair it were unsuccessful.", + "summary_subclaims": [ + "The case involves a late bronchopleural fistula after right extrapleural pneumonectomy for malignant mesothelioma.", + "Bronchoscopic attempts to repair the bronchopleural fistula were unsuccessful." + ] + }, + { + "id": "multiclinsum_test_2566_en.txt", + "fulltext": "A 79-year-old woman with loss of appetite was transferred from another hospital. On physical examination at the first visit, no abdominal tenderness and jaundice were noted. Initial laboratory findings were unremarkable, except for a high level of carbohydrate antigen 19–9 (CA19-9; 125.7 U/ml). Both serum HBs-antigen and HCV-antibody tests were negative.\nAbdominal computed tomography (CT) showed a 100 × 90 mm low-contrast tumor in segments 1, 2, 3, and 4 resulting in dilated bile ducts in B2, enlarged regional lymph nodes #3 and #7 [#3 and #7, according to the General Rules for Clinical and Pathological Studies on Primary Liver Cancer], and invasion of the inferior vena cava (IVC), left portal vein (LPV), middle hepatic vein (MHV), and middle hepatic artery (MHA) .\nPositron emission tomography with 18F-fluoro-D-deoxy-glucose (18F-FDG PET)/CT showed uptake by the primary liver tumor and regional lymph nodes . On imaging, the patient was diagnosed with intrahepatic cholangiocarcinoma (ICC) with regional lymph node metastases [cT2N1M0, cStage IIIB according to the Union for International Cancer Control (UICC) classification system].\nRadical surgical resection including combined vascular resection, reconstruction, and lymph node dissection was possible, but R0 resection is often difficult in cases of locally advanced ICC such as the present case; thus, it was not considered achievable during discussion in the multidisciplinary team (MDT) meeting. It was also thought that her prognosis would be poor due to inability to achieve R0 resection. Thus, she was treated with combined chemotherapy due to the lymph node metastases. The combination chemotherapy consisted of gemcitabine (1000 mg/m2) plus cisplatin (25 mg/m2) administered for 2 weeks followed by a 1-week respite, with a single course extending over 3 weeks.\nAfter 4 courses of combination chemotherapy without adverse events, CT showed a marked reduction of the primary tumor and metastatic lymph nodes. The size of the primary tumor had decreased to 30 × 60 mm, and the invasion of the IVC, LPV, MHV, and MHA had disappeared . The lymph node enlargement also disappeared, and the CA19-9 level decreased to within the normal range (9.3 U/ml) . The patient achieved a partial response (PR) as assessed using Response Evaluation Criteria In Solid Tumor (RECIST), and the post-chemotherapy TNM staging was ycT2N0M0 Stage II by the UICC criteria. At the MDT meeting, it was then decided that surgery could proceed. H1234-B-MHV, dissection of #1, #3, #5, and #7 lymph nodes, and pyloroplasty to prevent the delayed excretion of gastric contents due to the vagus nerve reflex associated with lymph node dissection were performed. She was discharged on postoperative day 15.\nThe histological examination showed scattered pigmented macrophages in the fibrotic tissue and inflammatory cell infiltration. No invasive carcinoma or epithelial carcinoma components were found. There were no viable carcinoma cells in the dissected lymph nodes . The pathological TNM staging was T0N0M0 according to the UICC criteria. In the MDT meeting, the decision was made not to proceed with adjuvant chemotherapy, for the reason that pCR had been achieved.\nShe remains alive with no evidence of disease 2 years after surgery without adjuvant chemotherapy.", + "fulltext_subclaims": [ + "The patient is a 79-year-old woman with loss of appetite.", + "On physical examination at the first visit, no abdominal tenderness was noted.", + "On physical examination at the first visit, jaundice was noted.", + "Initial laboratory findings were unremarkable, except for a high level of carbohydrate antigen 19–9 (CA19-9; 125.7 U/ml).", + "Both serum HBs-antigen and HCV-antibody tests were negative.", + "Abdominal computed tomography showed a 100 × 90 mm low-contrast tumor in segments 1, 2, 3, and 4.", + "Abdominal computed tomography showed dilated bile ducts in B2.", + "Abdominal computed tomography showed enlarged regional lymph nodes #3 and #7.", + "Abdominal computed tomography showed invasion of the inferior vena cava.", + "Abdominal computed tomography showed invasion of the left portal vein.", + "Abdominal computed tomography showed invasion of the middle hepatic vein.", + "Abdominal computed tomography showed invasion of the middle hepatic artery.", + "Positron emission tomography with 18F-FDG showed uptake by the primary liver tumor.", + "Positron emission tomography with 18F-FDG showed uptake by regional lymph nodes.", + "On imaging, the patient was diagnosed with intrahepatic cholangiocarcinoma with regional lymph node metastases.", + "The tumor was classified as cT2N1M0, cStage IIIB according to the UICC classification system.", + "Radical surgical resection including combined vascular resection, reconstruction, and lymph node dissection was possible.", + "R0 resection is often difficult in cases of locally advanced ICC.", + "It was not considered achievable to perform R0 resection during the MDT meeting.", + "It was thought that her prognosis would be poor due to inability to achieve R0 resection.", + "She was treated with combined chemotherapy due to the lymph node metastases.", + "The combination chemotherapy consisted of gemcitabine (1000 mg/m2) plus cisplatin (25 mg/m2).", + "The chemotherapy was administered for 2 weeks followed by a 1-week respite.", + "A single course of chemotherapy extended over 3 weeks.", + "After 4 courses of combination chemotherapy without adverse events, CT showed a marked reduction of the primary tumor.", + "After 4 courses of combination chemotherapy without adverse events, CT showed a marked reduction of the metastatic lymph nodes.", + "The size of the primary tumor had decreased to 30 × 60 mm.", + "The invasion of the IVC, LPV, MHV, and MHA had disappeared.", + "The lymph node enlargement also disappeared.", + "The CA19-9 level decreased to within the normal range (9.3 U/ml).", + "The patient achieved a partial response as assessed using RECIST.", + "The post-chemotherapy TNM staging was ycT2N0M0 Stage II by the UICC criteria.", + "At the MDT meeting, it was decided that surgery could proceed.", + "H1234-B-MHV, dissection of #1, #3, #5, and #7 lymph nodes, and pyloroplasty were performed.", + "She was discharged on postoperative day 15.", + "Histological examination showed scattered pigmented macrophages in the fibrotic tissue.", + "Histological examination showed inflammatory cell infiltration.", + "No invasive carcinoma or epithelial carcinoma components were found.", + "There were no viable carcinoma cells in the dissected lymph nodes.", + "The pathological TNM staging was T0N0M0 according to the UICC criteria.", + "In the MDT meeting, the decision was made not to proceed with adjuvant chemotherapy.", + "The reason for not proceeding with adjuvant chemotherapy was that pCR had been achieved.", + "She remains alive with no evidence of disease 2 years after surgery.", + "She did not receive adjuvant chemotherapy." + ], + "summary": "A 79-year-old woman was admitted to a local hospital with appetite loss. Computed tomography showed a 100 × 90 mm low-contrast tumor in the left hepatic lobe and segment 1 with invasion to the inferior vena cava (IVC), and several lymph nodes along the left gastric artery and lesser curvature were enlarged. Therefore, she was treated with a combined chemotherapy regimen of gemcitabine and cisplatin. After four courses, the tumor size decreased to 30 × 60 mm without invasion to the IVC. Left hepatectomy extending to segment 1 with bile duct resection combined with middle hepatic vein resection (H1234-B-MHV), dissection of regional lymph nodes and pyloroplasty were performed. After radical resection, pCR was achieved. She is alive with no evidence of disease, 2 years after surgery.", + "summary_subclaims": [ + "A 79-year-old woman was admitted to a local hospital with appetite loss.", + "Computed tomography showed a 100 × 90 mm low-contrast tumor in the left hepatic lobe and segment 1.", + "The tumor showed invasion to the inferior vena cava.", + "Several lymph nodes along the left gastric artery and lesser curvature were enlarged.", + "She was treated with a combined chemotherapy regimen of gemcitabine and cisplatin.", + "After four courses, the tumor size decreased to 30 × 60 mm.", + "There was no invasion to the IVC after chemotherapy.", + "Left hepatectomy extending to segment 1 with bile duct resection combined with middle hepatic vein resection (H1234-B-MHV) was performed.", + "Dissection of regional lymph nodes was performed.", + "Pyloroplasty was performed.", + "After radical resection, pCR was achieved.", + "She is alive with no evidence of disease.", + "She is 2 years after surgery." + ] + }, + { + "id": "multiclinsum_test_693_en.txt", + "fulltext": "The patient is a 2-year-4-month-old boy, who is the first child of his nonconsanguineous Chinese parents, a 26-year-old mother and a 27-year-old father, both of them are healthy. Following an uneventful pregnancy, he was born at 38 weeks of gestation with a birth weight of 3.15 kg. Feeding difficulties and poor suck had been noticed since birth. Hypotonia was apparent at age of 4 months. He showed severe developmental delay. He could not raise his head until 4 months old, sit unsupported till 11 months. At 2-year-4-month-old, he could not walk and speak any meaningful words. Eye contact and social smiling were enabling. He had recurrent respiratory tract infections, and hospitalized for severe pneumonia for several times. At 12 months old, his head circumference was 47 cm, weight was 11 kg. The boy had mild dysmorphism with flat nasal bridge, anteverted nares, small mouth, high-arched palate, low-set ears and cryptorchidism of the right side. Hand stereotypes including hand wringing and hand shaking presented at 8 months. He had no chronic constipation, no seizures. Magnetic resonance imaging (MRI) at age 1 year was unremarkable. Karyotype analysis was normal. Serum amino acid and urine organic acid screen were unremarkable.\nFamily history: The boy’s mother had two younger brothers. Both of them had severe developmental delay. The elder one could not walk or speak before he died at age of 5. The best motor function was sitting unaided. His brain computed tomography (CT) scan showed generalized cerebral atrophy. The younger one had a history of recurrent infections, died of a sever pneumonia at the age of 1y. He could not sit or walk alone during his life, speak no meaningful words yet. Both the mother and the grandmother were asymptomatic, they did not have any symptoms of depression, anxiety and compulsions. Figure showed the pedigrees of the family, the proband was showed by an arrow.\nGenomic DNAs from the peripheral blood leukocytes of the patient, his parents and the maternal grandmother were extracted using standard methods. MLPA (SALSA MLPA kit P015 MECP2, MRC-Holland, Amsterdam, Holland) was performed to detect large deletions or duplications of MECP2 gene as previously described . MLPA products were separated and analyzed using the ABI Prism 3100 Genetic Analyzer and Genescan software according to manufacturer’s recommendations.\nIn order to determine the precise size of the duplication, aCGH was performed on the mother’ DNA, using Affymetrix GeneChip System 3000Dx v.2 (by Tianjin kingmed center for clinical laboratory, Shanghai, China).\nFISH test was performed to interrogate the MECP2 copy number and to identify the location of the duplicated MECP2 gene in chromosome (done by Beijing Ahngook Pharm. Co., Ltd, Beijing, China).\nThe patterns of XCI of female carriers were analyzed according to the procedure described by Allen et al. . Inactivation was considered to be non- random if the ratio was > 70:30.", + "fulltext_subclaims": [ + "The patient is a 2-year-4-month-old boy.", + "He is the first child of his nonconsanguineous Chinese parents.", + "His mother is 26 years old.", + "His father is 27 years old.", + "Both parents are healthy.", + "He was born at 38 weeks of gestation.", + "His birth weight was 3.15 kg.", + "Feeding difficulties and poor suck had been noticed since birth.", + "Hypotonia was apparent at age of 4 months.", + "He showed severe developmental delay.", + "He could not raise his head until 4 months old.", + "He could not sit unsupported until 11 months.", + "At 2 years 4 months old, he could not walk.", + "At 2 years 4 months old, he could not speak any meaningful words.", + "Eye contact and social smiling were enabling.", + "He had recurrent respiratory tract infections.", + "He was hospitalized for severe pneumonia several times.", + "At 12 months old, his head circumference was 47 cm.", + "At 12 months old, his weight was 11 kg.", + "He had mild dysmorphism with flat nasal bridge.", + "He had anteverted nares.", + "He had a small mouth.", + "He had a high-arched palate.", + "He had low-set ears.", + "He had cryptorchidism of the right side.", + "Hand stereotypes including hand wringing and hand shaking presented at 8 months.", + "He had no chronic constipation.", + "He had no seizures.", + "Magnetic resonance imaging (MRI) at age 1 year was unremarkable.", + "Karyotype analysis was normal.", + "Serum amino acid and urine organic acid screen were unremarkable.", + "The boy’s mother had two younger brothers.", + "Both of the mother’s younger brothers had severe developmental delay.", + "The elder brother could not walk or speak before he died at age of 5.", + "The best motor function of the elder brother was sitting unaided.", + "The elder brother’s brain CT scan showed generalized cerebral atrophy.", + "The younger brother had a history of recurrent infections.", + "The younger brother died of severe pneumonia at the age of 1 year.", + "The younger brother could not sit or walk alone during his life.", + "The younger brother spoke no meaningful words yet.", + "Both the mother and the grandmother were asymptomatic.", + "They did not have any symptoms of depression.", + "They did not have any symptoms of anxiety.", + "They did not have any symptoms of compulsions.", + "Genomic DNAs from the peripheral blood leukocytes of the patient, his parents and the maternal grandmother were extracted using standard methods.", + "MLPA (SALSA MLPA kit P015 MECP2, MRC-Holland, Amsterdam, Holland) was performed to detect large deletions or duplications of MECP2 gene.", + "MLPA products were separated and analyzed using the ABI Prism 3100 Genetic Analyzer.", + "MLPA products were analyzed using Genescan software according to manufacturer’s recommendations.", + "aCGH was performed on the mother’s DNA using Affymetrix GeneChip System 3000Dx v.2.", + "FISH test was performed to interrogate the MECP2 copy number.", + "FISH test was performed to identify the location of the duplicated MECP2 gene in chromosome.", + "The patterns of XCI of female carriers were analyzed according to the procedure described by Allen et al.", + "Inactivation was considered to be non-random if the ratio was > 70:30." + ], + "summary": "We identified a Chinese family with three persons carry MECP2 gene duplication: a boy, his mother and his grandmother. The duplication segment which was detected by multiplex ligation-dependent probe amplification (MLPA) included gene MECP2, interleukin-1 receptor-associated kinase 1 (IRAK1), filamin A (FLNA), and L1 cell adhesion molecule (L1CAM). Furthermore, array comparative genomic hybridization (aCGH) was performed on the mother, showed that MECP2 containing duplication was 510 Kb (153,113,885-153,624,154), including 16 other genes except MECP2. The boy showed most symptoms of MECP2 duplication syndrome. His mother and maternal grandmother were asymptomatic. Both female carriers had a skewed X chromosome inactivation (XCI), which were 80:20 and 74:26 respectively.", + "summary_subclaims": [ + "We identified a Chinese family with three persons carry MECP2 gene duplication: a boy, his mother and his grandmother.", + "The duplication segment which was detected by multiplex ligation-dependent probe amplification (MLPA) included gene MECP2, interleukin-1 receptor-associated kinase 1 (IRAK1), filamin A (FLNA), and L1 cell adhesion molecule (L1CAM).", + "Array comparative genomic hybridization (aCGH) was performed on the mother, showed that MECP2 containing duplication was 510 Kb (153,113,885-153,624,154), including 16 other genes except MECP2.", + "The boy showed most symptoms of MECP2 duplication syndrome.", + "His mother and maternal grandmother were asymptomatic.", + "Both female carriers had a skewed X chromosome inactivation (XCI), which were 80:20 and 74:26 respectively." + ] + }, + { + "id": "multiclinsum_test_2468_en.txt", + "fulltext": "A previously healthy 29-year-old male with no medical history of respiratory illness, recurrent throat infections, or hospital admissions presented to the emergency department with a 3-day history of progressively worsening sore throat, odynophagia, and dysphagia. On presentation day, he started experiencing mild hoarseness and shortness of breath, especially when lying supine, which prompted seeking medical attention. On further questioning, the patient was not taking any prescribed medications and had no known drug allergies. He reported continuous e-cigarette use starting 2 days prior to the development of symptoms, minimal alcohol intake, and no use of recreational drugs.\nThe patient received intravenous Dexamethasone In the emergency department, which immediately improved his shortness of breath. A throat culture was negative for group A, B, and C Streptococcus. COVID-19 was ruled out with a PCR nasal swab. The total peripheral white blood cell count was mildly elevated, but the rest of the renal and metabolic panels were normal. A lateral soft tissue radiograph of the neck showed a poorly defined and thickened epiglottis with a classic thumb sign, indicating acute epiglottitis .\nConsidering his respiratory concerns, the Otolaryngology team was consulted. On examination, the patient was afebrile and was not experiencing trismus or stridor. Direct bedside laryngoscopy showed an enlarged, erythematous, and swollen epiglottis, partially obstructing the supraglottic region . Arytenoids were noted to be edematous bilaterally with normal vocal cord mobility.\nThe patient was admitted to the hospital for airway monitoring and was started on intravenous Ceftriaxone and oral Metronidazole. He was also given another dose of intravenous Dexamethasone and was asked to stop using his e-cigarette.\nThe patient’s condition improved significantly after 2 days, and a repeat laryngoscopy showed resolution of the swelling in the epiglottis . The patient was switched to oral Amoxicillin for 10 days and was discharged from the hospital.", + "fulltext_subclaims": [ + "The patient is a 29-year-old male.", + "The patient had no medical history of respiratory illness.", + "The patient had no medical history of recurrent throat infections.", + "The patient had no medical history of hospital admissions.", + "The patient had a 3-day history of progressively worsening sore throat.", + "The patient had odynophagia.", + "The patient had dysphagia.", + "On presentation day, the patient started experiencing mild hoarseness.", + "On presentation day, the patient started experiencing shortness of breath.", + "The shortness of breath was especially present when lying supine.", + "The shortness of breath prompted seeking medical attention.", + "The patient was not taking any prescribed medications.", + "The patient had no known drug allergies.", + "The patient reported continuous e-cigarette use starting 2 days prior to the development of symptoms.", + "The patient received intravenous Dexamethasone in the emergency department.", + "The intravenous Dexamethasone immediately improved the patient's shortness of breath.", + "A throat culture was negative for group A, B, and C Streptococcus.", + "A lateral soft tissue radiograph of the neck showed a poorly defined and thickened epiglottis.", + "The lateral soft tissue radiograph showed a classic thumb sign.", + "The thumb sign indicated acute epiglottitis.", + "The patient was afebrile.", + "Direct bedside laryngoscopy showed an enlarged, erythematous, and swollen epiglottis.", + "The epiglottis partially obstructed the supraglottic region.", + "The patient was admitted to the hospital.", + "The patient was started on intravenous Ceftriaxone.", + "The patient was started on oral Metronidazole.", + "The patient was given another dose of intravenous Dexamethasone.", + "The patient was asked to stop using his e-cigarette.", + "The patient’s condition improved significantly after 2 days.", + "A repeat laryngoscopy showed resolution of the swelling in the epiglottis.", + "The patient was switched to oral Amoxicillin.", + "The patient was discharged from the hospital." + ], + "summary": "A previously healthy 29-year-old male with daily e-cigarette use presented to the emergency department with a severe sore throat, dysphagia, mild hoarseness, and shortness of breath, especially when lying supine. A lateral neck soft tissue radiograph revealed a thickened epiglottis with a thumb sign. Direct bedside laryngoscopy showed a swollen epiglottis, partially obstructing the supraglottic region confirming the diagnosis of acute epiglottitis. Throat and nasal swabs were negative for streptococcus and COVID-19 infection, respectively. The patient's condition improved significantly after receiving intravenous Dexamethasone and antibiotics for 2 days. Repeat laryngoscopy showed the resolution of epiglottis swelling, and subjective symptoms had resolved entirely 2 weeks following the start of the treatment.", + "summary_subclaims": [ + "The patient is a 29-year-old male.", + "The patient has daily e-cigarette use.", + "The patient presented with a severe sore throat.", + "The patient had dysphagia.", + "The patient had mild hoarseness.", + "The patient had shortness of breath, especially when lying supine.", + "A lateral neck soft tissue radiograph showed a thickened epiglottis with a thumb sign.", + "Direct bedside laryngoscopy showed a swollen epiglottis.", + "The swollen epiglottis partially obstructed the supraglottic region.", + "The diagnosis was acute epiglottitis.", + "Throat swabs were negative for streptococcus.", + "Nasal swabs were negative for COVID-19.", + "The patient received intravenous Dexamethasone.", + "The patient received antibiotics.", + "The patient's condition improved significantly after 2 days of treatment.", + "Repeat laryngoscopy showed resolution of epiglottis swelling.", + "Subjective symptoms had resolved entirely 2 weeks following the start of the treatment." + ] + }, + { + "id": "multiclinsum_test_370_en.txt", + "fulltext": "A 63-year-old male visited a nearby hospital with a chief complaint of nausea and epigastric discomfort in March 2009. He consulted our institution in April 2009. Esophagogastroduodenoscopy (EGD) revealed a type 0–IIc moderately differentiated adenocarcinoma in the posterior wall of the gastric angle and a tubular adenoma in the greater curvature of the gastric antrum . An abdominal computed tomography (CT) scan showed no lymph node swelling, but a chest CT scan revealed masses of size 5.2 × 4.0 cm in the right upper lung lobe and 2.3 × 2.2 cm in the left upper lung lobe . The pretracheal, subcarinal and hilar lymph nodes were swollen. Transbronchial biopsy revealed squamous cell carcinoma. An 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan revealed a mass with intense FDG accumulation; the maximal standardized uptake values (SUVmax) were 18.6 in the right upper lung lobe, 22.3 in the left upper lung lobe, and 5.7 in the posterior wall of the gastric angle. The gastric cancer was cT1(SM), cN0, cM0, cStage IA according to the Japanese Classification of Gastric Carcinoma 13th edition . The pulmonary tumors were diagnosed to be right lung cancer with contralateral lung metastasis, staged as cT2, cN2, cM1(PUL), cStage IV according to the General Rule for Clinical and Pathological Record of Lung Cancer 6th edition .\nAs the lung cancer was advanced and the gastric cancer was early, treatment was focused on the lung cancer. Chemotherapy was administered with four courses of S-1 plus cisplatin, six courses of triweekly docetaxel, three courses of triweekly carboplatin plus paclitaxel, six courses of weekly carboplatin plus paclitaxel with 55 Gy of radiotherapy, and four courses of carboplatin plus gemcitabine. Each chemotherapy regimen was terminated because of progressive disease (PD) of the lung cancer. During this period, EGD was conducted every 3–6 months, and endoscopic stable disease (eSD) was confirmed. During a chemotherapy break between November 2012 and September 2014, PD of the lung cancer and endoscopic PD of the gastric cancer to a type 3 tumor were recognized. Chemotherapy was restarted with six courses of carboplatin plus nab-paclitaxel, then two courses of nab-paclitaxel, four courses of carboplatin plus irinotecan, and 5 months of afatinib. However, these regimens resulted in PD of the lung cancer and eSD of the gastric cancer . Finally, nivolumab as the ninth-line setting was administered in February 2016. After ten courses of biweekly nivolumab (3 mg/kg), a chest CT scan showed shrunken lung consolidations of the bilateral upper lobes . An FDG PET/CT scan indicated that the lung consolidation of the right upper lobe had an SUVmax of 4.09, which could be well explained by atelectasis. EGD showed redness and smooth elevation of the posterior wall of the gastric angle and biopsy revealed no malignancy . From August 2016, he was chemotherapy-free in a good general condition. During this period, chest CT and FDG PET/CT scan showed no progression of the lung cancer. The chemotherapy regimens and the transition of tumor markers including serum carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC) are summarized in Fig. . Transition of cytokeratin 19 fragment (CYFRA) and FDG PET/CT scans are shown elsewhere .\nHowever, the type 0–IIa tumor in the greater curvature of the gastric antrum, which had been pathologically diagnosed as a tubular adenoma, was diagnosed as a well-differentiated tubular adenocarcinoma in August 2017, and a type 0–IIc lesion in the lesser curvature of the gastric angle appeared and was diagnosed as a well-differentiated adenocarcinoma in March 2020 . It seemed that the 0–IIc tumor had not arisen from the epicenter, but from the margin of the primary gastric cancer. An abdominal CT scan did not show wall thickening of the stomach, swollen lymph nodes, or other distant metastases. An FDG PET/CT scan showed no progression, with an SUVmax of 3.89 in the right upper lung lobe.\nWe diagnosed that the lung cancer was in CR and that the gastric cancer had relapsed after endoscopic CR. Preoperative diagnoses were M, less, Type 0–IIc, ycT1a, ycN0, ycM0 ycStage I and L, Gre, Type 0–IIa, ycT1a, ycN0, ycM0, ycStage I according to the Japanese Classification of Gastric Carcinoma 15th edition . Laparoscopic gastrectomy with D1+ lymphadenectomy and Billroth-I reconstruction was performed. As the intraoperative frozen section revealed a small adenocarcinoma on the posterior wall of the proximal resection line, the stomach was additionally resected to confirm a negative proximal margin . Histopathological examination revealed three carcinoma lesions and a tubular adenoma : [I] M, Less, Type 0–IIc, 15 × 8 mm ; [II] L, Gre, Type 0–IIa, 15 × 12 mm; [III] M, Post, Type 0–IIb, 2 mm; [I–III] tub1, pT1a(M), Ly0, V0, pN0, M0, H0, P0, CY0, pStage IA ; [IV] tubular adenoma, low grade. Other than these tumors, no viable tumor cells or signs of tumor regression, including scars, necrosis, fibrosis, granulation, or mucin lakes, were found in the section of the whole posterior wall of the gastric body and the additionally resected stomach. The postoperative course was uneventful. This patient is doing well 1 month after surgery.", + "fulltext_subclaims": [ + "The patient is a 63-year-old male.", + "He visited a nearby hospital with a chief complaint of nausea and epigastric discomfort in March 2009.", + "He consulted our institution in April 2009.", + "Esophagogastroduodenoscopy (EGD) revealed a type 0–IIc moderately differentiated adenocarcinoma in the posterior wall of the gastric angle.", + "An abdominal computed tomography (CT) scan showed no lymph node swelling.", + "A chest CT scan revealed masses of size 5.2 × 4.0 cm in the right upper lung lobe and 2.3 × 2.2 cm in the left upper lung lobe.", + "The pretracheal, subcarinal and hilar lymph nodes were swollen.", + "Transbronchial biopsy revealed squamous cell carcinoma.", + "An 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan revealed a mass with intense FDG accumulation.", + "The maximal standardized uptake values (SUVmax) were 18.6 in the right upper lung lobe.", + "The SUVmax was 22.3 in the left upper lung lobe.", + "The SUVmax was 5.7 in the posterior wall of the gastric angle.", + "The gastric cancer was cT1(SM), cN0, cM0, cStage IA according to the Japanese Classification of Gastric Carcinoma 13th edition.", + "The pulmonary tumors were diagnosed to be right lung cancer with contralateral lung metastasis.", + "The pulmonary tumors were staged as cT2, cN2, cM1(PUL), cStage IV according to the General Rule for Clinical and Pathological Record of Lung Cancer 6th edition.", + "Treatment was focused on the lung cancer.", + "Chemotherapy was administered with four courses of S-1 plus cisplatin.", + "Chemotherapy was administered with six courses of triweekly docetaxel.", + "Chemotherapy was administered with three courses of triweekly carboplatin plus paclitaxel.", + "Chemotherapy was administered with six courses of weekly carboplatin plus paclitaxel with 55 Gy of radiotherapy.", + "Chemotherapy was administered with four courses of carboplatin plus gemcitabine.", + "Each chemotherapy regimen was terminated because of progressive disease (PD) of the lung cancer.", + "During this period, EGD was conducted every 3–6 months.", + "Endoscopic stable disease (eSD) was confirmed.", + "During a chemotherapy break between November 2012 and September 2014, PD of the lung cancer and endoscopic PD of the gastric cancer to a type 3 tumor were recognized.", + "Chemotherapy was restarted with six courses of carboplatin plus nab-paclitaxel.", + "Chemotherapy was restarted with two courses of nab-paclitaxel.", + "Chemotherapy was restarted with four courses of carboplatin plus irinotecan.", + "Chemotherapy was restarted with 5 months of afatinib.", + "These regimens resulted in PD of the lung cancer and eSD of the gastric cancer.", + "Nivolumab as the ninth-line setting was administered in February 2016.", + "After ten courses of biweekly nivolumab (3 mg/kg), a chest CT scan showed shrunken lung consolidations of the bilateral upper lobes.", + "An FDG PET/CT scan indicated that the lung consolidation of the right upper lobe had an SUVmax of 4.09.", + "The SUVmax of 4.09 could be well explained by atelectasis.", + "EGD showed redness and smooth elevation of the posterior wall of the gastric angle.", + "Biopsy revealed no malignancy.", + "From August 2016, he was chemotherapy-free in a good general condition.", + "Chest CT and FDG PET/CT scan showed no progression of the lung cancer.", + "The type 0–IIa tumor in the greater curvature of the gastric antrum, which had been pathologically diagnosed as a tubular adenoma, was diagnosed as a well-differentiated tubular adenocarcinoma in August 2017.", + "A type 0–IIc lesion in the lesser curvature of the gastric angle appeared and was diagnosed as a well-differentiated adenocarcinoma in March 2020.", + "It seemed that the 0–IIc tumor had not arisen from the epicenter, but from the margin of the primary gastric cancer.", + "An abdominal CT scan did not show wall thickening of the stomach.", + "An abdominal CT scan did not show swollen lymph nodes.", + "An abdominal CT scan did not show other distant metastases.", + "An FDG PET/CT scan showed no progression, with an SUVmax of 3.89 in the right upper lung lobe.", + "We diagnosed that the lung cancer was in CR.", + "We diagnosed that the gastric cancer had relapsed after endoscopic CR.", + "Preoperative diagnoses were M, less, Type 0–IIc, ycT1a, ycN0, ycM0 ycStage I and L, Gre, Type 0–IIa, ycT1a, ycN0, ycM0, ycStage I according to the Japanese Classification of Gastric Carcinoma 15th edition.", + "Laparoscopic gastrectomy with D1+ lymphadenectomy and Billroth-I reconstruction was performed.", + "As the intraoperative frozen section revealed a small adenocarcinoma on the posterior wall of the proximal resection line, the stomach was additionally resected to confirm a negative proximal margin.", + "Histopathological examination revealed three carcinoma lesions and a tubular adenoma.", + "[I] M, Less, Type 0–IIc, 15 × 8 mm.", + "[II] L, Gre, Type 0–IIa, 15 × 12 mm.", + "[III] M, Post, Type 0–IIb, 2 mm.", + "[I–III] tub1, pT1a(M), Ly0, V0, pN0, M0, H0, P0, CY0, pStage IA.", + "[IV] tubular adenoma, low grade.", + "Other than these tumors, no viable tumor cells or signs of tumor regression, including scars, necrosis, fibrosis, granulation, or mucin lakes, were found in the section of the whole posterior wall of the gastric body and the additionally resected stomach.", + "The postoperative course was uneventful.", + "This patient is doing well 1 month after surgery." + ], + "summary": "A 63-year-old male consulted our institution and was found to have gastric cancer cT1(SM)N0M0 Stage IA and lung cancer cT2N2M1(PUL) Stage IV. He received eight chemotherapy treatments plus radiation, but the lung disease remained progressive. Finally, he received nivolumab therapy and complete response of both cancers was obtained. The gastric cancer recurred, but was successfully treated by laparoscopic gastrectomy. The resected specimen revealed three lesions, each being pT1aN0M0 Stage IA. The primary gastric cancer seemed to have completely vanished without scarring.", + "summary_subclaims": [ + "The patient was found to have gastric cancer cT1(SM)N0M0 Stage IA.", + "The patient was found to have lung cancer cT2N2M1(PUL) Stage IV.", + "The patient received eight chemotherapy treatments plus radiation.", + "The lung disease remained progressive.", + "The patient received nivolumab therapy.", + "Complete response of both cancers was obtained.", + "The gastric cancer recurred.", + "The gastric cancer recurrence was successfully treated by laparoscopic gastrectomy.", + "The resected specimen revealed three lesions, each being pT1aN0M0 Stage IA.", + "The primary gastric cancer seemed to have completely vanished without scarring." + ] + }, + { + "id": "multiclinsum_test_2106_en.txt", + "fulltext": "A 54-year-old man attended the emergency department of the hospital with a painful locking of the right knee. He was trying to attain a kneeling position on the bed when his knee struck on the edge of the bed. Clinical examination revealed no palpable gap in the patellar tendon. The superior pole of the patella was projecting anteriorly and there was a prominent dimple below the patella. The patient was not able to perform straight leg raising. Plain radiographs confirmed a superior dislocation of the patella, which was manipulated by passing fingers under the prominent surface of patella, lower pole of patella was pushed posteriorly, and upper pole was pushed distally, gently flexing and then extending the knee which provided immediate pain relief. This procedure was done under the effect of intramuscular analgesia. The knee was then immobilized in a posterior long knee brace for three weeks. After three weeks, patient was active with pain-free range of movements and a stable right knee.", + "fulltext_subclaims": [ + "A 54-year-old man attended the emergency department of the hospital with a painful locking of the right knee.", + "He was trying to attain a kneeling position on the bed when his knee struck on the edge of the bed.", + "Clinical examination revealed no palpable gap in the patellar tendon.", + "The superior pole of the patella was projecting anteriorly.", + "There was a prominent dimple below the patella.", + "The patient was not able to perform straight leg raising.", + "Plain radiographs confirmed a superior dislocation of the patella.", + "The procedure was done under the effect of intramuscular analgesia.", + "The knee was then immobilized in a posterior long knee brace for three weeks.", + "After three weeks, the patient was active with pain-free range of movements.", + "After three weeks, the patient had a stable right knee." + ], + "summary": "A 54-year-old male presented with acute painful locking of knee after his knee struck on the edge of the bed while trying to attain a kneeling position on the bed. On clinical examination, the superior pole of patella protruded anteriorly and was very tender. The patellar tendon was found to be intact. Radiographs confirmed the diagnosis of superior dislocation of patella. The dislocation was reduced by closed method using intramuscular analgesia. The knee was immobilized for three weeks in a posterior long knee brace.", + "summary_subclaims": [ + "The patient is a 54-year-old male.", + "He presented with acute painful locking of the knee.", + "The knee injury occurred after it struck on the edge of the bed.", + "The injury occurred while trying to attain a kneeling position on the bed.", + "On clinical examination, the superior pole of the patella protruded anteriorly.", + "The superior pole of the patella was very tender.", + "The patellar tendon was found to be intact.", + "Radiographs confirmed the diagnosis of superior dislocation of the patella.", + "The dislocation was reduced by closed method.", + "Intramuscular analgesia was used during reduction.", + "The knee was immobilized for three weeks.", + "The knee was immobilized in a posterior long knee brace." + ] + }, + { + "id": "multiclinsum_test_2355_en.txt", + "fulltext": "A 4-month-old boy, weighing 6.3 kg, presented to the local hospital 18 days before the consultation with no apparent cause of dyspnea, cough, and sputum. Imaging revealed an anterior mediastinal occupancy, possible abnormal enlargement of the thymus, and bilateral pneumonia. No improvement was seen after antibiotic treatment was given. To clarify the etiology, an ultrasound-guided fine needle biopsy was performed, which showed normal thymic tissue with no evidence of malignancy. The patient was seen at our hospital for a significant worsening of symptoms, and the parents denied any other previous symptoms or comorbidities of the patient. On admission, body temperature was 37.1°C, blood pressure was 93/51 mmHg, pulse rate was 147 beats/min, and respiratory rate was 35 breaths/min. He had cyanotic lips, diminished breath sounds in both lungs, positive three concave sign, no fever, and ptosis. The peripheral blood leukocyte count was 10.38 × 109/L, with 12.8% neutrophils and 81% lymphocytes. Blood gas analysis data were pH 7.403, pCO2 40.7 mmHg, pO2 51.8 mmHg, ctHb 13.9 g/dl, sO2 85.4%, BE 0.7 mmol/L, cHCO3- 24.7 mmol/L. The ultrasound showed a significantly enlarged thymus with a soft texture and fair echogenicity. Chest radiographs showed large soft tissue shadows in the bilateral thoracic cavity .\nAfter admission, he received non-invasive ventilation, which relieved his breathing difficulties to some extent. Enhanced computed tomography scan of the chest revealed that the thymus was significantly enlarged, it had smooth margins, regular morphology, and mild uniform enhancement, both lungs were compressed, solid, and non-distended, and the distal segments of the left and right main bronchi and their branches were thinned, and the superior vena cava, right subclavian vein, and left cephalic brachial vein were thickened, which was considered as thymic hyperplasia . Further, the tumor markers alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), and human chorionic gonadotropin (HCG) in peripheral blood were checked within normal limits. Combining the patient's clinical features, imaging, and biopsy findings, TTH was considered. On the third day of admission, the patient's dyspnea further worsened and he underwent tracheal intubation. To relieve the compression of the lungs and heart and great vessels, exploratory thoracoscopic surgery was performed on the third day of admission.\nThe patient entered the operating room with a tracheal tube, awake and sedated, with pulse oximetry of 85%, a blood pressure of 55/40 mmHg, a heart rate of 101 beats/min, and an airway pressure of 26 cm H2O. After induction of anesthesia, the tracheal tube was removed and an Arndt5F bronchial blocker was placed in the right bronchus, followed by the insertion of a normal tracheal tube. To prevent airway collapse, muscle relaxants were not administered during anesthesia. Due to the patient's low blood pressure and slow heart rate, intraoperative blood pressure was maintained at 55–80/35–52 mmHg after pumping a small dose of dobutamine, and the heart rate fluctuated from 98 to 142 beats/min. Intraoperative blood oxygen fluctuated from 70%–100%.\nThe patient was placed in the left lateral recumbent position and a 5 mm Trocar was placed in the 8th intercostal space/midaxillary line, 5th intercostal space/anterior axillary line, and 6th intercostal space/posterior axillary line, respectively. Artificial pneumothorax was established at 6–8 mmHg pressure. We observed giant thymus-like tissue occupying the bilateral thoracic cavity, up to the roof of the pleura and down to the diaphragm. It had an intact envelope, a yellowish-white solid lobulated shape, and a soft texture, and these were consistent with the normal thymus appearance . It compressed but did not invade the surrounding structures and measured approximately 12 × 10 × 5 cm , with the phrenic nerve traveling at its margin. We used an electric scalpel to first free dissect and removed the mass occupying the right side of the thorax in its entirety, followed by freeing and removing most of the mass occupying the left side of the thorax, preserving part of the thymus in the left lobe and the volume of the preserved thymus is about 1/3 of the normal unilateral thymus in the age cohorts . And we carefully protected the phrenic nerves bilaterally during the operation. Finally, we enlarged one of the trocar holes to 2 cm and removed the tissue using a retrieval bag, and the weight of the resected mass was approximately 308 g . We placed one silicone drainage tube, with intraoperative bleeding of approximately 2 ml and an operative time of 90 min. The patient had his drainage tube removed 5 days after surgery and was discharged 7 days after surgery. Postoperative pathological histology showed enlarged lobular structures, clear corticomedullary demarcation, and visible thymic vesicles. Combined with the immunohistochemical staining results, it was considered consistent with true thymic hyperplasia . At the 2-month postoperative follow-up, the patient had no new symptoms or related complications. The routine blood test showed WBC 12.46*1012/L, LYMPH# 8.92*109/L, LYMPH% 71.6%. No recurrence was detected on chest x-ray and both lungs were well dilated .", + "fulltext_subclaims": [ + "The patient was a 4-month-old boy weighing 6.3 kg.", + "He presented 18 days before the consultation with dyspnea, cough, and sputum.", + "Imaging revealed an anterior mediastinal occupancy.", + "Imaging suggested possible abnormal enlargement of the thymus.", + "Imaging showed bilateral pneumonia.", + "No improvement was seen after antibiotic treatment.", + "An ultrasound-guided fine needle biopsy was performed.", + "The biopsy showed normal thymic tissue.", + "The biopsy showed no evidence of malignancy.", + "The patient was seen at our hospital for a significant worsening of symptoms.", + "The parents denied any other previous symptoms or comorbidities.", + "On admission, body temperature was 37.1°C.", + "On admission, blood pressure was 93/51 mmHg.", + "On admission, pulse rate was 147 beats/min.", + "On admission, respiratory rate was 35 breaths/min.", + "The patient had cyanotic lips.", + "The patient had diminished breath sounds in both lungs.", + "The patient had a positive three concave sign.", + "The patient had no fever.", + "The patient had ptosis.", + "The peripheral blood leukocyte count was 10.38 × 109/L.", + "The peripheral blood neutrophil percentage was 12.8%.", + "The peripheral blood lymphocyte percentage was 81%.", + "Blood gas analysis showed pH 7.403.", + "Blood gas analysis showed pCO2 40.7 mmHg.", + "Blood gas analysis showed pO2 51.8 mmHg.", + "Blood gas analysis showed ctHb 13.9 g/dl.", + "Blood gas analysis showed sO2 85.4%.", + "Blood gas analysis showed BE 0.7 mmol/L.", + "Blood gas analysis showed cHCO3- 24.7 mmol/L.", + "The ultrasound showed a significantly enlarged thymus.", + "The ultrasound showed the thymus had a soft texture.", + "The ultrasound showed the thymus had fair echogenicity.", + "Chest radiographs showed large soft tissue shadows in the bilateral thoracic cavity.", + "The patient received non-invasive ventilation.", + "Non-invasive ventilation relieved his breathing difficulties to some extent.", + "Enhanced computed tomography scan showed the thymus was significantly enlarged.", + "Enhanced computed tomography scan showed the thymus had smooth margins.", + "Enhanced computed tomography scan showed the thymus had regular morphology.", + "Enhanced computed tomography scan showed mild uniform enhancement.", + "Enhanced computed tomography scan showed both lungs were compressed.", + "Enhanced computed tomography scan showed both lungs were solid.", + "Enhanced computed tomography scan showed both lungs were non-distended.", + "Enhanced computed tomography scan showed the distal segments of the left and right main bronchi and their branches were thinned.", + "Enhanced computed tomography scan showed the superior vena cava, right subclavian vein, and left cephalic brachial vein were thickened.", + "The findings were considered as thymic hyperplasia.", + "Tumor markers alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), and human chorionic gonadotropin (HCG) were within normal limits.", + "Combining the patient's clinical features, imaging, and biopsy findings, TTH was considered.", + "On the third day of admission, the patient's dyspnea further worsened.", + "On the third day of admission, the patient underwent tracheal intubation.", + "Exploratory thoracoscopic surgery was performed on the third day of admission.", + "The patient entered the operating room with a tracheal tube.", + "The patient was awake and sedated.", + "Pulse oximetry was 85%.", + "Blood pressure was 55/40 mmHg.", + "Heart rate was 101 beats/min.", + "Airway pressure was 26 cm H2O.", + "After induction of anesthesia, the tracheal tube was removed.", + "An Arndt5F bronchial blocker was placed in the right bronchus.", + "A normal tracheal tube was inserted.", + "Muscle relaxants were not administered during anesthesia.", + "Intraoperative blood pressure was maintained at 55–80/35–52 mmHg.", + "Intraoperative heart rate fluctuated from 98 to 142 beats/min.", + "Intraoperative blood oxygen fluctuated from 70%–100%.", + "The patient was placed in the left lateral recumbent position.", + "A 5 mm Trocar was placed in the 8th intercostal space/midaxillary line.", + "A 5 mm Trocar was placed in the 5th intercostal space/anterior axillary line.", + "A 5 mm Trocar was placed in the 6th intercostal space/posterior axillary line.", + "Artificial pneumothorax was established at 6–8 mmHg pressure.", + "Giant thymus-like tissue occupied the bilateral thoracic cavity.", + "The tissue extended up to the roof of the pleura.", + "The tissue extended down to the diaphragm.", + "The tissue had an intact envelope.", + "The tissue had a yellowish-white solid lobulated shape.", + "The tissue had a soft texture.", + "The tissue was consistent with the normal thymus appearance.", + "The tissue compressed but did not invade the surrounding structures.", + "The tissue measured approximately 12 × 10 × 5 cm.", + "The phrenic nerve traveled at the margin of the tissue.", + "An electric scalpel was used to first free dissect and remove the mass occupying the right side of the thorax in its entirety.", + "Most of the mass occupying the left side of the thorax was freed and removed.", + "Part of the thymus in the left lobe was preserved.", + "The volume of the preserved thymus was about 1/3 of the normal unilateral thymus in the age cohorts.", + "The phrenic nerves were carefully protected bilaterally during the operation.", + "One of the trocar holes was enlarged to 2 cm.", + "The tissue was removed using a retrieval bag.", + "The weight of the resected mass was approximately 308 g.", + "One silicone drainage tube was placed.", + "Intraoperative bleeding was approximately 2 ml.", + "The operative time was 90 min.", + "The drainage tube was removed 5 days after surgery.", + "The patient was discharged 7 days after surgery.", + "Postoperative pathological histology showed enlarged lobular structures.", + "Postoperative pathological histology showed clear corticomedullary demarcation.", + "Postoperative pathological histology showed visible thymic vesicles.", + "Combined with immunohistochemical staining results, it was considered consistent with true thymic hyperplasia.", + "At the 2-month postoperative follow-up, the patient had no new symptoms or related complications.", + "Routine blood test showed WBC 12.46*1012/L.", + "Routine blood test showed LYMPH# 8.92*109/L.", + "Routine blood test showed LYMPH% 71.6%.", + "No recurrence was detected on chest x-ray.", + "Both lungs were well dilated." + ], + "summary": "A 4-month-old boy was admitted to the hospital with no apparent cause of dyspnea for 18 days, with cough and sputum. On examination, the patient was found to have cyanotic lips, diminished breath sounds in both lungs, and a positive three concave sign. There was no fever or ptosis. Preoperative imaging showed large soft tissue shadows in the bilateral thoracic cavity, with basic symmetry between the right and left sides. Tumor markers were within the normal range. Ultrasound-guided fine needle biopsy showed normal thymic structures with no evidence of malignancy. As his symptoms worsened, he eventually underwent unilateral thoracic approach video-assisted thoracoscopic exploratory surgery, during which a large mass occupying the bilateral thoracic cavity was removed in a separate block and part of the thymus in the left lobe was preserved. Pathological examination confirmed true thymic hyperplasia (TTH). No relevant complications occurred at the 2-month postoperative follow-up.", + "summary_subclaims": [ + "A 4-month-old boy was admitted to the hospital with no apparent cause of dyspnea for 18 days.", + "The patient had cough and sputum.", + "On examination, the patient had cyanotic lips.", + "On examination, the patient had diminished breath sounds in both lungs.", + "On examination, the patient had a positive three concave sign.", + "There was no fever.", + "There was no ptosis.", + "Preoperative imaging showed large soft tissue shadows in the bilateral thoracic cavity.", + "Tumor markers were within the normal range.", + "Ultrasound-guided fine needle biopsy showed normal thymic structures.", + "Ultrasound-guided fine needle biopsy showed no evidence of malignancy.", + "The patient underwent unilateral thoracic approach video-assisted thoracoscopic exploratory surgery.", + "A large mass occupying the bilateral thoracic cavity was removed in a separate block.", + "Part of the thymus in the left lobe was preserved.", + "Pathological examination confirmed true thymic hyperplasia (TTH).", + "No relevant complications occurred at the 2-month postoperative follow-up." + ] + }, + { + "id": "multiclinsum_test_2939_en.txt", + "fulltext": "Our patient was a healthy 72-year-old Japanese man, with an unremarkable previous medical history. He was referred to our institution due to jaundice and impaired hepatic function found during a health examination. We observed stenosis in the middle bile duct on a preoperative endoscopic retrograde cholangiopancreatography (ERCP) image , whereas class V adenocarcinoma was detected by biliary abrasive cytology. The preoperative image indicated low bifurcation in the posterior segmental branch. A pancreaticoduodenectomy was conducted due to the diagnosis of middle bile duct cancer. Because our patient had no post-surgical complaints, even given mildly increased inflammation, he was discharged on postoperative day 22. However, we found increased inflammation on blood withdrawal when he visited our institution on postoperative day 30. On computed tomography (CT) we observed abscess formation with suspected bile leakage around the hepaticojejunal site and posterior segmental bile duct dilatation . We initially completed percutaneous transhepatic biliary drainage (PTBD). During contrast radiography with PTBD, only the posterior segmental branch was visualized, but there was no bile leakage into the elevated jejunum . Later, we completed contrast radiography from the hepaticojejunal anastomosis site with the use of an endoscope, and only the anterior segmental branch and left branch were visualized . Thus, we concluded the damage was on the low bifurcation in the posterior segmental branch. Bile (approximately 250 ml/day) was discharged by PTBD on consecutive days.\nWe conducted a drip infusion cholecystocholangiography (DIC)-CT test to determine the positional relationship between bile duct and elevated jejunum. We found contrast agent discharged into the elevated jejunum from the anterior segmental branch and left branch . We dorsally visualized the bile duct in the isolated posterior segmental branch . From the DIC-CT test, we at that time detected an unclear positional relation between elevated jejunum and posterior segmental branch. We determined that there was no intrusion of other organs between the elevated jejunum and the bile duct. Consequently, percutaneous transhepatic internal drainage of the posterior isolated bile duct, to the elevated jejunum, could be conducted.\nTo secure the bile duct, we made a puncture in the bile duct under CT guidance , and visualized the hepaticojejunal anastomosis site by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle, and verified the vibrations with the endoscope. We found a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion . We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum . We removed all drains after percutaneously inserting an uncovered metallic stent (5 cm 10 mm; Fig. ). Our patient’s subsequent clinical course was unremarkable, and he visits our institution on an out-patient basis, without stent occlusion even after 6 months.", + "fulltext_subclaims": [ + "The patient was a 72-year-old Japanese man.", + "The patient had an unremarkable previous medical history.", + "The patient was referred due to jaundice and impaired hepatic function found during a health examination.", + "Stenosis in the middle bile duct was observed on a preoperative endoscopic retrograde cholangiopancreatography (ERCP) image.", + "Class V adenocarcinoma was detected by biliary abrasive cytology.", + "The preoperative image indicated low bifurcation in the posterior segmental branch.", + "A pancreaticoduodenectomy was conducted due to the diagnosis of middle bile duct cancer.", + "The patient had no post-surgical complaints.", + "The patient was discharged on postoperative day 22.", + "Increased inflammation was found on blood withdrawal on postoperative day 30.", + "Abscess formation with suspected bile leakage around the hepaticojejunal site was observed on computed tomography (CT).", + "Posterior segmental bile duct dilatation was observed on CT.", + "Percutaneous transhepatic biliary drainage (PTBD) was initially completed.", + "During contrast radiography with PTBD, only the posterior segmental branch was visualized.", + "There was no bile leakage into the elevated jejunum during contrast radiography with PTBD.", + "Contrast radiography from the hepaticojejunal anastomosis site with an endoscope visualized only the anterior segmental branch and left branch.", + "The damage was concluded to be on the low bifurcation in the posterior segmental branch.", + "Bile (approximately 250 ml/day) was discharged by PTBD on consecutive days.", + "A drip infusion cholecystocholangiography (DIC)-CT test was conducted.", + "Contrast agent was discharged into the elevated jejunum from the anterior segmental branch and left branch.", + "The bile duct in the isolated posterior segmental branch was dorsally visualized.", + "An unclear positional relation between the elevated jejunum and posterior segmental branch was detected from the DIC-CT test.", + "There was no intrusion of other organs between the elevated jejunum and the bile duct.", + "Percutaneous transhepatic internal drainage of the posterior isolated bile duct to the elevated jejunum could be conducted.", + "A puncture in the bile duct was made under CT guidance.", + "The hepaticojejunal anastomosis site was visualized by inserting an endoscope.", + "The bile duct wall was vibrated by inserting a guide wire through a puncture needle.", + "The vibrations were verified with the endoscope.", + "A partially compressed elevated jejunal wall was found upon guide wire insertion.", + "A puncture needle penetration into the elevated jejunum was verified by endoscope on insertion.", + "An 8.5-Fr pigtail catheter was successfully inserted into the elevated jejunum.", + "All drains were removed after percutaneously inserting an uncovered metallic stent.", + "The patient’s subsequent clinical course was unremarkable.", + "The patient visits our institution on an out-patient basis.", + "There was no stent occlusion even after 6 months." + ], + "summary": "A 72-year-old Japanese man underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer. We had a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed. We conducted a drip infusion cholecystocholangiography-computed tomography test to determine the positional relationship between his bile duct and elevated jejunum. To secure the bile duct we punctured the bile duct under computed tomography guidance, and the hepaticojejunal anastomosis site was visualized by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle and verified the vibrations with the endoscope. We observed a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion. We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum. We removed all drains after percutaneously inserting an uncovered metallic stent. Our patient's subsequent clinical course was unremarkable. He visits our institution as an out-patient and has had no stent occlusion even after 6 months.", + "summary_subclaims": [ + "The patient is a 72-year-old Japanese man.", + "The patient underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer.", + "There was a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed.", + "A drip infusion cholecystocholangiography-computed tomography test was conducted to determine the positional relationship between the bile duct and elevated jejunum.", + "The bile duct was punctured under computed tomography guidance.", + "The hepaticojejunal anastomosis site was visualized by inserting an endoscope.", + "A guide wire was inserted through a puncture needle to vibrate the bile duct wall.", + "The vibrations were verified with the endoscope.", + "A partially compressed elevated jejunal wall was observed upon guide wire insertion.", + "A puncture needle penetration into the elevated jejunum was verified by endoscope on insertion.", + "An 8.5-Fr pigtail catheter was successfully inserted into the elevated jejunum.", + "All drains were removed after percutaneously inserting an uncovered metallic stent.", + "The patient's subsequent clinical course was unremarkable.", + "The patient visits the institution as an out-patient.", + "There has been no stent occlusion even after 6 months." + ] + }, + { + "id": "multiclinsum_test_7_en.txt", + "fulltext": "In this report, we describe the case of 55-year-old lady of Central African origin with primary open-angle glaucoma (POAG) who underwent bilateral XEN gel surgery.\nThe patient was initially referred by her general ophthalmologist to a tertiary glaucoma center with intraocular pressures (IOP) of 38 mm Hg and 22 mm Hg in the right and the left eyes, respectively. She had been diagnosed with POAG several years before and had been managed with two selective laser trabeculoplasties (SLT) and maximal medical therapy including oral acetazolamide (Vifor Pharma, Bern, Switzerland), despite mediocre self-reported compliance. She had a positive family history for open-angle glaucoma in her mother. At the time of presentation, her best-corrected visual acuity was 10/10 in both eyes on a decimal chart (6/6 Snellen) in slightly myopic eyes (−0.75 D and −1.25 D spherical equivalent in the right and the left eyes, respectively). Slit lamp examination revealed a deep and quiet AC and a clear crystalline lens. Cup/disk ratio was 0.8 in the right eye with an inferior notch and 0.7 in the left eye with a superior notch. Gonioscopy showed bilaterally open angles. Pachymetry was 580 μm and 585 μm in the right and the left eyes, respectively. Automated visual field examination (Octopus, Haag Streit, Koeniz, Switzerland) showed bilateral nasal quadrantanopsia. Optical coherence tomography imaging (Spectralis OCT, Heidelberg Engineering AG, Germany) of the retinal nerve fiber layer (RNFL) showed generally reduced RNFL thicknesses bilaterally, with complete atrophy of the RNFL inferiorly in the left eye. Brain MRI imaging was unremarkable.\nBilateral mitomycin C-augmented XEN gel stent implantation was organized with a target IOP ≤18 mm Hg. Surgeries were performed following standard protocols described in the literature. No intraoperative complications were noted, and the patient received a standard postoperative treatment of topical combined tobramycin and dexamethasone (Novartis Pharma, Basel, Switzerland) in decreasing regime. The right eye recovered uneventfully, with IOP normalizing between 12 mm Hg and 16 mm Hg at 3 months, with no additional therapy. The left eye developed a 2-mm hyphema on the first day following surgery, associated with dense RBC in the AC and corneal edema. The initial intraocular pressure was 2 mm Hg, which gradually improved with scopolamine (OmniVision Pharma, Puchheim, Germany) to 9 mm Hg at day 3. After 8 days, the hyphema had completely resolved and IOP was stable at 12 mm Hg. After 1 month, the patient presented to her postoperative follow-up with an IOP of 50 mm Hg in the left eye. On examination, the filtration bleb was shallow but diffuse, the iridocorneal angle was open, the XEN gel stent was well-positioned, and no clear obstruction was visible on its intraocular tip.\nIntraocular pressure was reduced using topical and intravenous medications, and an emergency revision procedure was organized in theater. The absence of filtration through the stent was confirmed intraoperatively and the blocked tube was removed. It was sent for macroscopic analysis to confirm the cause of the obstruction and was replaced by a new XEN gel implant. The patient made good recovery without any postoperative complications, and at 1-month, her IOP was stable at 17 mm Hg.\nThe macroscopic examination confirmed obstruction of the XEN gel stent on its AC extremity, with translucent cell fragments . No fibrin, blood clot, or other type of tissue could be identified within the obstructed tube.", + "fulltext_subclaims": [ + "The patient is a 55-year-old lady of Central African origin.", + "The patient has primary open-angle glaucoma.", + "The patient underwent bilateral XEN gel surgery.", + "The patient was referred with intraocular pressures of 38 mm Hg in the right eye.", + "The patient was referred with intraocular pressures of 22 mm Hg in the left eye.", + "The patient had been diagnosed with POAG several years before.", + "The patient had two selective laser trabeculoplasties.", + "The patient was on maximal medical therapy including oral acetazolamide.", + "The patient had mediocre self-reported compliance.", + "The patient had a positive family history for open-angle glaucoma in her mother.", + "Best-corrected visual acuity was 10/10 in both eyes.", + "Cup/disk ratio was 0.8 in the right eye with an inferior notch.", + "Cup/disk ratio was 0.7 in the left eye with a superior notch.", + "Gonioscopy showed bilaterally open angles.", + "Pachymetry was 580 μm in the right eye.", + "Pachymetry was 585 μm in the left eye.", + "Automated visual field examination showed bilateral nasal quadrantanopsia.", + "Optical coherence tomography imaging showed generally reduced RNFL thicknesses bilaterally.", + "Brain MRI imaging was unremarkable.", + "Bilateral mitomycin C-augmented XEN gel stent implantation was organized.", + "The target IOP was ≤18 mm Hg.", + "Surgeries were performed following standard protocols described in the literature.", + "No intraoperative complications were noted.", + "The patient received topical combined tobramycin and dexamethasone.", + "The right eye recovered uneventfully.", + "The right eye had IOP normalizing between 12 mm Hg and 16 mm Hg at 3 months.", + "The left eye developed a 2-mm hyphema on the first day following surgery.", + "The initial intraocular pressure in the left eye was 2 mm Hg.", + "The hyphema in the left eye had completely resolved after 8 days.", + "IOP was stable at 12 mm Hg after 8 days.", + "After 1 month, the patient presented with an IOP of 50 mm Hg in the left eye.", + "The filtration bleb was shallow but diffuse.", + "The XEN gel stent was well-positioned.", + "An emergency revision procedure was organized.", + "The absence of filtration through the stent was confirmed intraoperatively.", + "The blocked tube was removed.", + "The tube was sent for macroscopic analysis.", + "The patient made good recovery without any postoperative complications.", + "At 1-month, her IOP was stable at 17 mm Hg.", + "Macroscopic examination confirmed obstruction of the XEN gel stent on its AC extremity.", + "Translucent cell fragments were identified within the obstructed tube." + ], + "summary": "We describe the case of a 55-year-old female patient with primary open-angle glaucoma (POAG) who underwent bilateral XEN gel surgery. Her left eye developed a 2 mm postoperative hyphema, which resolved spontaneously within 8 days. Intraocular pressure (IOP) normalized at 12 mm Hg and increased to 50 mm Hg after 1 month in an otherwise normal-looking eye. Intraoperative examination revealed a nonfunctioning XEN gel stent, which was replaced and sent for laboratory analysis. Macroscopic examination of the tube confirmed obstruction with cellular debris. Tube replacement restored good filtration.", + "summary_subclaims": [ + "The patient is a 55-year-old female.", + "The patient has primary open-angle glaucoma.", + "The patient underwent bilateral XEN gel surgery.", + "The left eye developed a 2 mm postoperative hyphema.", + "The hyphema resolved spontaneously within 8 days.", + "Intraocular pressure normalized at 12 mm Hg.", + "Intraocular pressure increased to 50 mm Hg after 1 month.", + "The eye was otherwise normal-looking.", + "Intraoperative examination revealed a nonfunctioning XEN gel stent.", + "The stent was replaced and sent for laboratory analysis.", + "Macroscopic examination of the tube confirmed obstruction with cellular debris.", + "Tube replacement restored good filtration." + ] + }, + { + "id": "multiclinsum_test_1358_en.txt", + "fulltext": "A 55-year-old man was admitted to The Second Affiliated Hospital of Zhejiang University School of Medicine (Hangzhou, China) in October 2021 with rapidly worsening heart failure.\nThe patient had been experiencing heart failure for 3 mo, but had begun to experience chest tightness, dyspnea, edema, and fatigue after activity.\nThe patient had undergone a pulmonary resection 20 years prior to address carcinoma in situ; his current disease state was considered stable.\nThe patient’s personal and family histories were unremarkable.\nThe patient’s blood pressure was 87/49 mmHg, pulse rate was 101 beats per minute with a regular rhythm, and O2 saturation was 97% at room air. Physical examination revealed that he had clear lungs and normal heart sounds with no murmurs or gallops on auscultation. His lower extremities showed mild bilateral pitting edema. No enlargement of lymph nodes, liver, or spleen was found.\nLaboratory tests showed normal findings in a complete blood count and comprehensive metabolic panel. The levels of serum lactate dehydrogenase and β2-microglobulin were within normal limits. However, the levels of brain natriuretic peptide (385.7 pg/mL; normal: < 100) and troponin T (0.058 ng/mL; normal: < 0.014) were over the normal upper limits. Creatinine was within the normal range (at 51.9 μmol/L), while urine analysis was negative for protein. Quantitation of 24-h urinary lambda light chain showed a level of 365.2 mg. Quantitative serum immunoglobulin analyses demonstrated normal levels of IgG (at 10.5 g/L), IgA (at 2.01 g/L), and IgM (at 0.28 g/L). Serum immunofixation was used to evaluate an underlying gammopathy and showed lambda light chain proteinemia. The level of serum-free lambda light chain (FLC) was normal (at 15.56 mg/L), with the difference between the involved and uninvolved serum FLC levels being 6.75 mg/L. A bone marrow aspirate smear showed 5% infiltration of plasma cells, while flow cytometry analysis showed an abnormal population of plasma cells that accounted for 5.8% of normal cells, most of which were positive for surface CD38, CD56, CD138, and cytoplasmic λ light-chain. The fluorescence in situ hybridization test was negative, which included a 1q21 amplification, 13q14 deletion, p53 deletion, and translocation of t (4; 14), t (11; 14), t (14; 16).\nPositron emission tomography/computerized tomography (PET/CT) was performed and showed no abnormal metabolic lesions. An electrocardiogram showed low voltages in the limb leads. Echocardiogram revealed severe left ventricular hypertrophy, a reduced left ventricle ejection fraction of 38.1%, and an elevated left ventricular filling pressure E/A of more than 2.04. Cardiovascular magnetic resonance imaging (MRI) showed the morphologic phenotype of increased left ventricle wall thickness, while 99technetium pyrophosphate (99mTc-PYP) planar scintigraphy showed a heart-to-contralateral ratio of 1.31.\nCardiac amyloidosis was considered as a possible etiology of the cardiomyopathy due to the left ventricle thickness on echocardiogram and the heart-to-contralateral ratio of 1.31 on 99mTc-PYP. An endomyocardial biopsy was performed with electron microscopy, revealing fibroid deposits in the myocardium and after Congo-red staining, fibrous tissue with apple green birefringence visualized by polarized light microscopy . Immunohistochemistry analysis showed dominant positivity for monoclonal lambda light chains.", + "fulltext_subclaims": [ + "The patient was admitted to The Second Affiliated Hospital of Zhejiang University School of Medicine in October 2021.", + "The patient had been experiencing heart failure for 3 mo.", + "The patient had undergone a pulmonary resection 20 years prior to address carcinoma in situ.", + "The patient’s blood pressure was 87/49 mmHg.", + "The patient’s pulse rate was 101 beats per minute.", + "The patient’s O2 saturation was 97% at room air.", + "The patient’s lower extremities showed mild bilateral pitting edema.", + "The levels of brain natriuretic peptide were 385.7 pg/mL.", + "The levels of troponin T were 0.058 ng/mL.", + "The level of serum-free lambda light chain was 15.56 mg/L.", + "A bone marrow aspirate smear showed 5% infiltration of plasma cells.", + "Flow cytometry analysis showed an abnormal population of plasma cells that accounted for 5.8% of normal cells.", + "The fluorescence in situ hybridization test was negative.", + "An electrocardiogram showed low voltages in the limb leads.", + "Echocardiogram revealed severe left ventricular hypertrophy.", + "Echocardiogram showed a reduced left ventricle ejection fraction of 38.1%.", + "Cardiac amyloidosis was considered as a possible etiology of the cardiomyopathy.", + "An endomyocardial biopsy was performed.", + "Electron microscopy revealed fibroid deposits in the myocardium.", + "Immunohistochemistry analysis showed dominant positivity for monoclonal lambda light chains." + ], + "summary": "We report the case of a 55-year-old man presenting with heart failure who was diagnosed with cardiac AL amyloidosis by an endomyocardial biopsy. He experienced a short-term hematological remission with no organ response after being administered a bortezomib-daratumumab containing regimen. The treatment was switched to pomolidomide due to pulmonary involvement and progressive pleural effusion, in which flow cytometry analysis showed abnormal plasma cells. After two cycles of this regimen, the pleural effusion was controlled effectively with no recurrence.", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "The patient presented with heart failure.", + "The patient was diagnosed with cardiac AL amyloidosis by an endomyocardial biopsy.", + "The patient experienced a short-term hematological remission.", + "The patient had no organ response.", + "The patient was administered a bortezomib-daratumumib containing regimen.", + "The treatment was switched to pomalidomide.", + "The treatment switch was due to pulmonary involvement.", + "The treatment switch was due to progressive pleural effusion.", + "Flow cytometry analysis showed abnormal plasma cells.", + "The pleural effusion was controlled effectively after two cycles of the pomalidomide regimen.", + "The pleural effusion did not recur." + ] + }, + { + "id": "multiclinsum_test_1739_en.txt", + "fulltext": "A 45-year-old woman was admitted with acute onset of short-term memory loss, intermittent headaches, dizzy spells and an obvious change in personality which had progressed over a ten day period. Intermittent vomiting, confusion and unsteadiness were also reported. These symptoms worsened over the three days prior to admission. Her past medical history included an episode of herpes simplex virus infection about one month earlier. A non-smoker, she consumed alcohol in moderation.\nOn examination, she had disorientation of time and place and her mini mental score was found to be 2/10. Confusion with nominal aphasia was also noted. She was apyrexial. Cardiovascular, respiratory and gastrointestinal system examination was unremarkable. Neurological examination showed normal power and tone in both arms and legs with normal symmetrical deep tendon reflexes. Her gait, coordination, cranial nerve and fundus examination were normal.\nInvestigations revealed a normal full blood count and unremarkable routine biochemical tests and inflammatory markers. Contrast enhanced CT of the brain showed low attenuation areas adjacent to the anterior ends of both thalami. Appearances were reported as an unusual form of cerebral infarctions and it was suggested that other pathology could not be ruled out.\nExamination of CSF revealed isolated lymphocytosis. Glucose and protein were normal. Polymerase Chain Reaction (PCR) tests for herpes simplex virus and varicella zoster were negative.\nElectroencephalogram (EEG) recordings showed intermittent low frequency activity suggesting focal abnormality of cortical function, probably associated with a vascular or structural lesion but no clear evidence of encephalitis or epileptiform activity. On MRI scan of the head there were bilateral symmetrical lesions in both thalami giving high signal changes on the T2 weighted and proton density images. In addition there were asymmetrical multiple high signal areas on T2 weighted images in both cerebellar hemispheres. CNS lymphoma and demyelination were two of the possible differential diagnoses for the MRI appearances. Subsequently performed vertebral and carotid MR angiograms were reported to be normal and the possibility of basilar artery aneurysm or thrombosis was ruled out.\nOver a period of two weeks there was a progressive worsening of confusion, with increasing agitation, memory impairment and personality change. With deterioration in Glasgow Coma Scale (GCS), the possibility of other systemic causes was considered. She was empirically treated for encephalitis and/or viral meningitis and a possibility of vasculitis was considered, for which a trial of methylprednisolone and cyclophosphamide was given without any significant benefit. Further investigations, looking for a possible systemic cause, by an autoantibody screen including anti-neutrophil cytoplasmic antibodies and a vasculitic screen was reported as normal.\nA saline contrast transthoracic echo confirmed a diagnosis of Patent Foramen Ovale (PFO) as a significant number of microbubbles appeared in the left atrium within 3 cardiac cycles of their appearance in the right atrium and this was facilitated with valsalva release. Further assessment for atrial septal separation was not done with transesophageal echocardiogram because of the above positive findings from the transthoracic echocardiogram.\nA diagnosis of embolic basilar artery ischemic stroke with thalamic and cerebellar infarcts secondary to paradoxical embolism via the PFO was made. She was started on aspirin and clopidogrel and later anticoagulated with warfarin before she underwent percutaneous device closure.\nThere are three treatment options in patients with a presumed paradoxical embolism and PFO.\n1. Antiplatelet therapy with aspirin\n2. Oral anticoagulation with warfarin\n3. Surgical or percutaneous device closure\nDespite the growing evidence for association between PFO and atrial septal aneurysm with paradoxical embolism causing neurological events there is no consensus as how to treat a cryptogenic stroke and none of the above treatments have been evaluated in randomised controlled trials.\nThere was a gradual improvement over four weeks and subsequently the patient went on to have a complete recovery without any neurological or physical residual effects.\nLater she underwent percutaneous endovascular closure of the PFO with a Biostar device. In our patient percutaneous device closure was used because of her young age and absence of deep vein thrombosis or procoagulant state. It was felt inappropriate to leave the patient on life long warfarin with all the risks that anticoagulation might entail. Our patient had further follow up after the device closure of the PFO and had had no further episodes of transient ischaemic attack or any recurrence of stroke.", + "fulltext_subclaims": [ + "The patient was a 45-year-old woman.", + "She had acute onset of short-term memory loss.", + "She had intermittent headaches.", + "She had dizziness.", + "She had an obvious change in personality.", + "The personality change had progressed over a ten day period.", + "She had intermittent vomiting.", + "She had confusion.", + "She had unsteadiness.", + "The symptoms worsened over the three days prior to admission.", + "Her past medical history included an episode of herpes simplex virus infection about one month earlier.", + "She was a non-smoker.", + "She consumed alcohol in moderation.", + "On examination, she had disorientation of time and place.", + "Her mini mental score was 2/10.", + "Confusion with nominal aphasia was noted.", + "She was apyrexial.", + "Cardiovascular, respiratory, and gastrointestinal system examination was unremarkable.", + "Neurological examination showed normal power and tone in both arms and legs.", + "Neurological examination showed normal symmetrical deep tendon reflexes.", + "Her gait, coordination, cranial nerve, and fundus examination were normal.", + "Contrast enhanced CT of the brain showed low attenuation areas adjacent to the anterior ends of both thalami.", + "The CT appearances were reported as an unusual form of cerebral infarctions.", + "It was suggested that other pathology could not be ruled out.", + "CSF examination revealed isolated lymphocytosis.", + "CSF glucose and protein were normal.", + "PCR tests for herpes simplex virus and varicella zoster were negative.", + "EEG showed intermittent low frequency activity.", + "EEG suggested focal abnormality of cortical function.", + "MRI showed bilateral symmetrical lesions in both thalami giving high signal changes on T2 weighted and proton density images.", + "MRI showed asymmetrical multiple high signal areas on T2 weighted images in both cerebellar hemispheres.", + "CNS lymphoma was one of the possible differential diagnoses.", + "Demyelination was one of the possible differential diagnoses.", + "Vertebral and carotid MR angiograms were reported to be normal.", + "The possibility of basilar artery aneurysm or thrombosis was ruled out.", + "Over two weeks, there was a progressive worsening of confusion.", + "There was increasing agitation.", + "There was memory impairment.", + "There was personality change.", + "With deterioration in GCS, the possibility of other systemic causes was considered.", + "She was empirically treated for encephalitis and/or viral meningitis.", + "A trial of methylprednisolone and cyclophosphamide was given.", + "The trial of methylprednisolone and cyclophosphamide was without significant benefit.", + "An autoantibody screen including anti-neutrophil cytoplasmic antibodies was reported as normal.", + "A saline contrast transthoracic echo confirmed a diagnosis of Patent Foramen Ovale.", + "A diagnosis of embolic basilar artery ischemic stroke with thalamic and cerebellar infarcts secondary to paradoxical embolism via the PFO was made.", + "She was started on aspirin and clopidogrel.", + "She was later anticoagulated with warfarin.", + "She underwent percutaneous device closure.", + "There are three treatment options in patients with a presumed paradoxical embolism and PFO.", + "Antiplatelet therapy with aspirin is one treatment option.", + "Oral anticoagulation with warfarin is one treatment option.", + "Surgical or percutaneous device closure is one treatment option.", + "There is no consensus on how to treat a cryptogenic stroke.", + "None of the treatments have been evaluated in randomised controlled trials.", + "There was a gradual improvement over four weeks.", + "The patient had a complete recovery without any neurological or physical residual effects.", + "She underwent percutaneous endovascular closure of the PFO with a Biostar device.", + "Percutaneous device closure was used because of her young age.", + "Percutaneous device closure was used because of the absence of deep vein thrombosis.", + "Percutaneous device closure was used because of the absence of a procoagulant state.", + "It was felt inappropriate to leave the patient on lifelong warfarin.", + "The patient had further follow up after the device closure.", + "She had no further episodes of transient ischaemic attack.", + "She had no recurrence of stroke." + ], + "summary": "Unexplained rapid onset of confusion with amnesia and minimal neurological deficits can be a manifestation of various systemic causes of which stroke, either ischemic or hemorrhagic, is one. Thorough and systematic evaluation of these patients can be highly rewarding in terms of optimizing patient outcome. We report the case of a 45-year-old woman whose initial presentation was with acute onset of confusion, memory loss with personality change and headaches. A differential diagnosis of systemic illness and cerebral pathology was entertained. She was empirically treated for neurological infection. Brain imaging revealed bilateral thalamic and cerebellar infarction. Further evaluation with an aim to define the etiology, revealed the diagnosis of Patent Foramen Ovale with paradoxical embolism. The differential diagnosis of unexplained rapid onset of confusion, amnesia with minimal motor neurological deficits and relevant appropriate investigations are discussed in this case report.", + "summary_subclaims": [ + "Unexplained rapid onset of confusion with amnesia and minimal neurological deficits can be a manifestation of various systemic causes of which stroke, either ischemic or hemorrhagic, is one.", + "Thorough and systematic evaluation of these patients can be highly rewarding in terms of optimizing patient outcome.", + "We report the case of a 45-year-old woman whose initial presentation was with acute onset of confusion, memory loss with personality change and headaches.", + "A differential diagnosis of systemic illness and cerebral pathology was entertained.", + "She was empirically treated for neurological infection.", + "Brain imaging revealed bilateral thalamic and cerebellar infarction.", + "Further evaluation with an aim to define the etiology, revealed the diagnosis of Patent Foramen Ovale with paradoxical embolism.", + "The differential diagnosis of unexplained rapid onset of confusion, amnesia with minimal motor neurological deficits and relevant appropriate investigations are discussed in this case report." + ] + }, + { + "id": "multiclinsum_test_3275_en.txt", + "fulltext": "An 86-year-old male, who had a previous history of hypertension and coronary artery disease had shortness of breath. He was admitted to our hospital due to heart failure (HF). He had undergone percutaneous coronary interventions in the circumflex artery in 2019 and the left anterior descending artery in 2020 both at another hospital. The patient was asymptomatic before admission. Blood pressure and heart rate were 176/91 mmHg and 85 b.p.m., respectively. Bilateral leg oedema was observed, with systolic murmur on auscultation. Chest X-ray revealed pleural effusion and congestion. Electrocardiogram (ECG) was within normal range. Blood test revealed elevated brain natriuretic peptide (150.4 pg/mL, normal range: <100 pg/mL). His STS and EuroSCORE 2 were 10.8 and 9.4, respectively. Trans-thoracic echocardiogram (TTE) revealed a left ventricular (LV) ejection fraction of 66% and a LV diastolic diameter of 41 mm. Calcified aortic valve was observed. The peak velocity of the aortic valve was 3.5 m/s, and the mean aortic valve pressure gradient (PG) was 33 mmHg. The aortic valve area (AVA) using the Doppler method was 0.78 cm2. The presence of a VSD can affect TTE-derived peak velocity and mean PG.1 Membranous VSD and double-chambered right ventricle (DCRV) were observed in cardiac computed tomography (CT). Trans-oesophageal echocardiogram (TOE), CT, and catheter-based AVA were 0.6–0.7 cm2. The calcium score was 2150 AgU. Based on these findings, we diagnosed his AS severe.\n\nCardiac CT showed his cardiac anatomy was suitable for TAV implantation (TAVI). Annulus perimeter, Valsalva diameter, and coronary heights of left coronary artery and right coronary artery were 66.1, 29.1, 14.6, and 18.7 mm, respectively. The VSD orifice was located 3.5–7.3 mm from the aortic valve annulus, and the orifice diameter was 3.8 mm. A thin sub-aortic band (thickness <1 mm) was attached to the LV outflow tract (LVOT). Coronary angiogram showed no significant stenosis and widely open stents. The catheter-based PG between LV apex and aorta was 27 mmHg. No PG was observed between LV apex and LVOT. The right heart catheterization showed normal wedge pressure (17 mmHg) and slightly decreased cardiac index (2.1 L/min/m2). Pulmonary hypertension (mean pressure: 38 mmHg) and a PG of 50 mmHg between high-pressure and low-pressure chamber of right ventricle (RV) were observed. The catheter-based Qp/Qs ratio was 1.9. We diagnosed severe AS in combination with left-to-right (L–R) shunt, due to VSD, as the leading cause of the patient’s HF. These findings fulfilled the indication for invasive treatment for AS and VSD based on the guideline.\n\nSurgical aortic valve replacement, VSD closure, myectomy of the RV, and sub-aortic band resection treatment options were discussed with the heart team. The surgical team deemed not to be a surgical candidate because of the patient’s age, high risk of surgery and frailty (Clinical Frailty Scale: 5).4 As a result, a TAVI procedure with VSD orifice coverage using a valve skirt was planned as the interventional treatment option. We selected a 26-mm Evolut Pro Plus™ valve. Despite an increased risk of cardiac structural change due to pressing of sub-aortic band and/or injury of orifice of VSD and potentially deep implantation induced complete heart block, the valve could be deployed without complications. To treat AS and L–R shunt, the valve was selected because the valve has a long skirt at the bottom of the valve, which could cover the VSD orifice completely. Meanwhile, since the VSD orifice was located 3.5–7.3 mm below the annulus level, we deployed the valve 9 mm from the annulus level to cover the entire orifice of VSD with the valve skirt. We carefully deployed the valve by watching TOE to confirm no structural damage was made. The valve did not interfere with mitral valve movement. No leak across the valve and complete coverage of the VSD orifice with the valve skirt was observed by TOE. The amount of L–R shunt decreased. The catheter-based Qp/Qs ratio decreased from 1.9 to 1.2. Trans-thoracic echocardiogram–based aortic valve PG decreased from 33 to 2 mmHg. Post-procedural TOE revealed no leakage and a decrease in L–R shunt. The post-procedural ECG finding was unchanged (sinus rhythm, PR interval: 194 s and QRS duration: 70 ms). The patient was discharged from hospital 7 days after the procedure. He had not been admitted to hospital since discharge.", + "fulltext_subclaims": [ + "The patient is an 86-year-old male.", + "He had a previous history of hypertension.", + "He had a previous history of coronary artery disease.", + "He had shortness of breath.", + "He was admitted to the hospital due to heart failure.", + "He had undergone percutaneous coronary interventions in the circumflex artery in 2019.", + "He had undergone percutaneous coronary interventions in the left anterior descending artery in 2020.", + "The interventions were performed at another hospital.", + "The patient was asymptomatic before admission.", + "Blood pressure was 176/91 mmHg.", + "Heart rate was 85 b.p.m.", + "Bilateral leg oedema was observed.", + "A systolic murmur was heard on auscultation.", + "Chest X-ray revealed pleural effusion.", + "Chest X-ray revealed congestion.", + "Electrocardiogram was within normal range.", + "Brain natriuretic peptide was 150.4 pg/mL.", + "The normal range for brain natriuretic peptide is <100 pg/mL.", + "STS was 10.8.", + "EuroSCORE 2 was 9.4.", + "Trans-thoracic echocardiogram revealed a left ventricular ejection fraction of 66%.", + "Trans-thoracic echocardiogram revealed a left ventricular diastolic diameter of 41 mm.", + "A calcified aortic valve was observed.", + "The peak velocity of the aortic valve was 3.5 m/s.", + "The mean aortic valve pressure gradient was 33 mmHg.", + "The aortic valve area using the Doppler method was 0.78 cm2.", + "The presence of a VSD can affect TTE-derived peak velocity and mean PG.", + "Membranous VSD was observed in cardiac computed tomography.", + "Double-chambered right ventricle was observed in cardiac computed tomography.", + "Trans-oesophageal echocardiogram, CT, and catheter-based AVA were 0.6–0.7 cm2.", + "The calcium score was 2150 AgU.", + "Based on these findings, the patient was diagnosed with severe aortic stenosis.", + "Cardiac CT showed the cardiac anatomy was suitable for TAV implantation.", + "The annulus perimeter was 66.1 mm.", + "The Valsalva diameter was 29.1 mm.", + "The VSD orifice was located 3.5–7.3 mm from the aortic valve annulus.", + "The VSD orifice diameter was 3.8 mm.", + "A thin sub-aortic band was attached to the LV outflow tract.", + "Coronary angiogram showed no significant stenosis.", + "The catheter-based pressure gradient between LV apex and aorta was 27 mmHg.", + "No pressure gradient was observed between LV apex and LVOT.", + "Right heart catheterization showed normal wedge pressure of 17 mmHg.", + "Right heart catheterization showed a slightly decreased cardiac index of 2.1 L/min/m2.", + "Pulmonary hypertension with a mean pressure of 38 mmHg was observed.", + "A pressure gradient of 50 mmHg between high-pressure and low-pressure chambers of the right ventricle was observed.", + "The catheter-based Qp/Qs ratio was 1.9.", + "Severe aortic stenosis in combination with left-to-right shunt due to VSD was diagnosed as the leading cause of heart failure.", + "These findings fulfilled the indication for invasive treatment for aortic stenosis and VSD.", + "Surgical aortic valve replacement, VSD closure, myectomy of the right ventricle, and sub-aortic band resection were discussed.", + "The surgical team deemed the patient not a surgical candidate.", + "The surgical team cited the patient’s age as a reason not to perform surgery.", + "The surgical team cited high risk of surgery as a reason not to perform surgery.", + "The surgical team cited frailty as a reason not to perform surgery.", + "A TAVI procedure with VSD orifice coverage using a valve skirt was planned.", + "A 26-mm Evolut Pro Plus™ valve was selected.", + "The valve has a long skirt at the bottom, which could cover the VSD orifice completely.", + "The valve was deployed 9 mm from the annulus level.", + "The valve was deployed to cover the entire orifice of VSD with the valve skirt.", + "The valve was deployed by watching TOE to confirm no structural damage.", + "The valve did not interfere with mitral valve movement.", + "No leak across the valve was observed by TOE.", + "Complete coverage of the VSD orifice with the valve skirt was observed by TOE.", + "The amount of left-to-right shunt decreased.", + "The catheter-based Qp/Qs ratio decreased from 1.9 to 1.2.", + "Trans-thoracic echocardiogram–based aortic valve pressure gradient decreased from 33 to 2 mmHg.", + "Post-procedural TOE revealed no leakage.", + "Post-procedural TOE revealed a decrease in left-to-right shunt.", + "Post-procedural ECG finding was unchanged.", + "Post-procedural ECG showed sinus rhythm.", + "Post-procedural ECG showed a PR interval of 194 ms.", + "Post-procedural ECG showed a QRS duration of 70 ms.", + "The patient was discharged from hospital 7 days after the procedure.", + "The patient had not been admitted to hospital since discharge." + ], + "summary": "An 86-year-old male was admitted to our hospital with congestive heart failure due to low-flow low-gradient severe AS, a membranous VSD, a sub-aortic band, and a double-chambered right ventricle (RV). The patient was not deemed to be a surgical candidate because of advanced age and frailty even though surgical aortic valve replacement, VSD closure, sub-aortic band resection, and myectomy of RV would be considered as definitive treatment. Instead, we performed TAVI and VSD orifice closure using the skirt part of the self-expanding valve (26 mm Evolut Pro Plus™) because VSD occluder is not approved and thus not available in our country. The trans-catheter procedure resulted in a reduction of the mean aortic valve pressure gradient improved from 33 to 2 mmHg and a decrease in the shunt flow (Qp/Qs) from 1.9 to 1.2. The patient’s heart failure improved, and he was discharged to home 7 days after the procedure. He remained well and had not been admitted to hospital since discharge.", + "summary_subclaims": [ + "The patient was an 86-year-old male.", + "The patient was admitted to the hospital with congestive heart failure.", + "The patient had low-flow low-gradient severe AS.", + "The patient had a membranous VSD.", + "The patient had a sub-aortic band.", + "The patient had a double-chambered right ventricle.", + "The patient was not deemed to be a surgical candidate.", + "Surgical aortic valve replacement, VSD closure, sub-aortic band resection, and myectomy of RV would be considered as definitive treatment.", + "TAVI was performed using a 26 mm Evolut Pro Plus™ self-expanding valve.", + "VSD orifice closure was performed using the skirt part of the self-expanding valve.", + "A VSD occluder is not approved and thus not available in our country.", + "The mean aortic valve pressure gradient improved from 33 to 2 mmHg.", + "The shunt flow (Qp/Qs) decreased from 1.9 to 1.2.", + "The patient’s heart failure improved.", + "The patient was discharged to home 7 days after the procedure.", + "The patient remained well and had not been admitted to hospital since discharge." + ] + }, + { + "id": "multiclinsum_test_1243_en.txt", + "fulltext": "A 74-year-old woman was referred for CABG treatment. She had a history of diabetes mellitus and dyslipidemia and previously underwent percutaneous stenting of the mid right coronary artery and the proximal left anterior descending artery (LAD). Preoperative coronary angiography revealed 90% in-stent stenosis of the proximal LAD and 75% stenosis of the diagonal branch . In addition, she had three instances of in-stent stenosis at the LAD. Whenever restenosis was diagnosed, the implementation of percutaneous coronary intervention (PCI) was repeated. Taking this history into consideration, we decided to perform a left ITA (LITA)-LAD bypass and a right ITA (RITA) diagonal branch bypass. The ITAs were mobilized as skeletonized grafts. We routinely used nicorandil (4 mg/h) and diltiazem (4 mg/h) during CABG operation for the prevention of vasospasm.\nAt first, we performed RITA diagonal bypass. Subsequently, we performed anastomosis of LITA-LAD bypass. After CABG, the patient had stable circulation (BP 126/54 mmHg, HR 62 bpm) without changes in ST segment as monitored by electrocardiogram. When we examined blood flow of the RITA diagonal bypass, transit time flow measurement revealed reasonable blood flow (flow rate 20 mL/min, pulsative index 3.4, diastolic flow of 82%). On the other hand, the LITA graft showed comparatively poorer blood flow (flow rate 15 mL/min, pulsative index 2.1, diastolic flow 74%) than the RITA graft. Flow competition between the RITA and LITA was unlikely to occur considering the location of the stenotic lesion. In addition, taking into the consideration the perfused region of the LAD and the severe stenosis in the stent, the graft blood flow was too low and technical anastomotic stenosis was suspected. We re-anastomosed the LITA-LAD bypass. However, even after re-anastomosis of LITA-LAD bypass, transit time flow measurement revealed worsening of graft flow compared to before (LITA-LAD: flow rate 7 mL/min, pulsatile index 4.8, diastolic flow 68%; RITA diagonal: flow rate 11 mL/min, pulsatile index 5.6, diastolic flow 76%). We immediately closed the wound and moved the patient to a hybrid operating room to examine the causes of this progressively low graft flow.\nWe performed coronary angiography and detected vasospasms in the native coronary arteries without ST elevation, as seen on the electrocardiogram. We performed intracoronary injections of verapamil (5 mg) and isosorbide dinitrate (6 mg) through the ITA graft, but no improvement was observed. We subsequently injected fasudil (20 mg) through the LITA and observed that coronary flow through the LITA graft improved (thrombolysis in myocardial infarction risk score of 3) . The intracoronary fasudil injection did not cause systemic hypotension, as demonstrated by the postinjection measurement of 86/56 mmHg compared with the preinjection measurement of 93/52 mmHg. We subsequently applied intra-aortic balloon pumping to secure coronary blood flow.\nOn postoperative day 1, coronary angiography revealed a patent bypass graft and sufficient coronary runoff . Electrocardiogram showed no ischemic changes. Peak postoperative CK, CK-MB, and troponin T were 582 U/L (41–153 U/L), 7.6 IU/L (4–18 IU/L), and 0.307 ng/mL (0–0.014 ng/mL), respectively. The patient experienced an uneventful clinical course without vasospasm recurrence and was discharged on postoperative day 11.", + "fulltext_subclaims": [ + "A 74-year-old woman was referred for CABG treatment.", + "She had a history of diabetes mellitus.", + "She had a history of dyslipidemia.", + "She previously underwent percutaneous stenting of the mid right coronary artery.", + "She previously underwent percutaneous stenting of the proximal left anterior descending artery.", + "Preoperative coronary angiography revealed 90% in-stent stenosis of the proximal LAD.", + "Preoperative coronary angiography revealed 75% stenosis of the diagonal branch.", + "She had three instances of in-stent stenosis at the LAD.", + "Whenever restenosis was diagnosed, the implementation of percutaneous coronary intervention was repeated.", + "We decided to perform a left ITA-LAD bypass.", + "We decided to perform a right ITA diagonal branch bypass.", + "The ITAs were mobilized as skeletonized grafts.", + "We routinely used nicorandil (4 mg/h) during CABG operation.", + "We routinely used diltiazem (4 mg/h) during CABG operation.", + "We performed RITA diagonal bypass first.", + "We performed anastomosis of LITA-LAD bypass.", + "After CABG, the patient had stable circulation.", + "After CABG, the patient had a blood pressure of 126/54 mmHg.", + "After CABG, the patient had a heart rate of 62 bpm.", + "Transit time flow measurement revealed reasonable blood flow in the RITA diagonal bypass.", + "Transit time flow measurement showed a flow rate of 20 mL/min in the RITA diagonal bypass.", + "Transit time flow measurement showed a pulsative index of 3.4 in the RITA diagonal bypass.", + "Transit time flow measurement showed a diastolic flow of 82% in the RITA diagonal bypass.", + "The LITA graft showed comparatively poorer blood flow than the RITA graft.", + "Flow competition between the RITA and LITA was unlikely.", + "The graft blood flow was too low.", + "Technical anastomotic stenosis was suspected.", + "We re-anastomosed the LITA-LAD bypass.", + "Transit time flow measurement revealed worsening of graft flow after re-anastomosis.", + "We immediately closed the wound.", + "We moved the patient to a hybrid operating room.", + "We performed coronary angiography.", + "We detected vasospasms in the native coronary arteries.", + "We performed intracoronary injections of verapamil.", + "We performed intracoronary injections of isosorbide dinitrate.", + "We injected fasudil through the LITA.", + "Coronary flow through the LITA graft improved.", + "The intracoronary fasudil injection did not cause systemic hypotension.", + "We applied intra-aortic balloon pumping.", + "On postoperative day 1, coronary angiography revealed a patent bypass graft.", + "On postoperative day 1, coronary angiography showed sufficient coronary runoff.", + "Electrocardiogram showed no ischemic changes.", + "Peak postoperative CK was 582 U/L.", + "Peak postoperative CK-MB was 7.6 IU/L.", + "Peak postoperative troponin T was 0.307 ng/mL.", + "The patient experienced an uneventful clinical course.", + "The patient was discharged on postoperative day 11." + ], + "summary": "A 74-year-old woman who had three instances of in-stent stenosis at the left anterior descending artery (LAD) was referred for CABG treatment. Preoperative coronary angiography showed 90% in-stent stenosis of the proximal LAD and 75% stenosis of the diagonal branch. We performed a left internal thoracic artery (LITA)-LAD bypass and a right internal thoracic artery (RITA) diagonal branch bypass. After anastomosis, transit time flow measurement revealed poor blood flow of LITA-LAD bypass even after re-anastomosis. We performed coronary angiography and detected a vasospasm in the native coronary arteries, which was not relieved using conventional vasodilators (calcium channel blockers, isosorbide dinitrate, and nicorandil) However, we were able to relieve the coronary vasospasm by administering fasudil (a Rho kinase inhibitor) injection without causing systemic hypotension.", + "summary_subclaims": [ + "The patient was a 74-year-old woman.", + "She had three instances of in-stent stenosis at the left anterior descending artery.", + "She was referred for CABG treatment.", + "Preoperative coronary angiography showed 90% in-stent stenosis of the proximal LAD.", + "Preoperative coronary angiography showed 75% stenosis of the diagonal branch.", + "A left internal thoracic artery-LAD bypass was performed.", + "A right internal thoracic artery diagonal branch bypass was performed.", + "Transit time flow measurement revealed poor blood flow of LITA-LAD bypass even after re-anastomosis.", + "Coronary angiography detected a vasospasm in the native coronary arteries.", + "The vasospasm was not relieved using conventional vasodilators.", + "Fasudil injection was administered.", + "Fasudil injection relieved the coronary vasospasm.", + "Fasudil injection did not cause systemic hypotension." + ] + }, + { + "id": "multiclinsum_test_2270_en.txt", + "fulltext": "A 43-year-old Chinese Han woman with a history of GD was referred to our department for recurrent cough, expectoration for 2 months, and hemoptysis accompanied by fever for 1 week. Physical examination of the neck showed a slightly enlarged and homogenous thyroid gland, and a bilateral lung examination by auscultation was unremarkable. Her medical history was significant only for GD, which had developed 5 years previously and was treated with PTU. She had no history of other cardiovascular or cerebrovascular risk factors; allergic diseases including asthma, allergic rhinitis, or urticarial; and psychosocial disorders and no family history of autoimmune diseases. PTU was initially started at 300 mg/day and decreased to 100 mg/day once the euthyroid status was obtained.\nIn the fourth year of treatment, the patient started nonsteroidal anti-inflammatory drug (NSAID) treatment for arthralgia. In the fifth year of treatment, she developed recurrent cough and expectoration accompanied by malaise and asthenia but denied any experience of a rash, weight loss, or myalgia. After 2 months of ineffective treatment with antibiotics, the patient developed hemoptysis and fever, with a peak temperature of 37.9°C. Chest CT showed diffuse alveolar infiltrates, and pneumonia was considered. Moxifloxacin was then added to treat the bacterial infection. Two weeks later, however, the patient still had fever, cough, and hemoptysis. Repeat CT scan showed much more severe lesions with diffuse, bilateral, predominantly lower lobe nodular infiltrates and ground-glass opacity . A diffuse segmental hemorrhage was noted on bronchoscopy with a needlepoint hemorrhage and partial fusion in the submembrane along the left main bronchus spreading to the opening of the left upper lobe .\nExamination of the bronchial lavage fluid revealed 98% macrophages with iron staining positive for siderophages, and negative culture findings. Laboratory examinations revealed normal free triiodothyronine (2.18 pg/mL, normal range [NR] = 2 - 4.4), free thyroxine (0.98 ng/dL, NR = 0.93 - 1.7), and thyroid stimulating hormone (1.05 uIU/mL, NR = 0.27 - 4.2); low thyroglobulin (0.5 ng/mL, NR = 1.4 - 7.8); significantly elevated thyroglobulin antibody (> 4000 IU/mL, NR = 0 - 115) and antithyroid peroxidase antibody (256.4 IU/mL, NR = 0 - 34); gradually increased erythrocyte sedimentation rate (ESR; 80 - 112 mm/h, NR = 0 - 20); and slightly increased C-reactive protein (CRP; 39 mg/L, NR = 0 - 8). Enzyme-linked immunosorbent assays were positive for MPO-ANCA and proteinase 3 (PR3)-ANCA, while immunofluorescent assays were positive for p-ANCA and c-ANCA. The complete blood cell count indicated slight anemia, with a decrease in hemoglobin (HGB) from 123 g/L to 89 g/L (NR = 113 - 151). Coagulation study revealed a slightly elevated D-dimer (1.11 mg/L, NR < 0.55).\nLiver and kidney functions were normal. Antinuclear antibody, anti-extractable nuclear antigen, and anti-double-stranded DNA were not detected. Pulmonary function test items were normal. Abdominal ultrasonography and cerebral magnetic resonance imaging were unremarkable. Thyroid ultrasonography disclosed a diffusely enlarged thyroid gland with hypervascularity indicative of GD. Based on these findings, this patient was diagnosed with PTU-induced ANCA-positive pulmonary vasculitis with DAH. The PTU was discontinued promptly, and an intravenous injection of methylprednisolone (80 mg/day) was initiated. Three days later, the steroid dose was changed to 40 mg/day. One week later, the therapy was changed to oral prednisolone, which was then tapered over next 12 weeks. There was significant improvement in respiratory symptoms and fever 1 week after the start of prednisolone treatment and PTU withdrawal. Within days, antithyroid antibody titers and ESR decreased markedly.\nApproximately 1 month after our observation, the serum was tested negative for ANCA, and ESR and HGB level were normal. In addition, chest CT indicated restoration of the lungs; it showed rapid improvement in the pulmonary pathology with an almost complete recovery in the parenchyma that was subsequently confirmed with bronchoscopy . After 6 months of follow-up, the patient was asymptomatic at 3 months of follow-up with a negative ANCA. Whole blood and thyroid function tests revealed normal ESR, CRP, and D-dimer levels. The steroid dose was tapered. At the 6-month follow-up, steroids were discontinued, and the ANCA remained negative. The patient’s condition remains stable.", + "fulltext_subclaims": [ + "The patient is a 43-year-old Chinese Han woman.", + "She has a history of Graves' disease (GD).", + "She was referred for recurrent cough, expectoration for 2 months, and hemoptysis with fever for 1 week.", + "Physical examination showed a slightly enlarged and homogenous thyroid gland.", + "Bilateral lung auscultation was unremarkable.", + "Her medical history was significant only for GD.", + "GD had developed 5 years previously.", + "She was treated with PTU.", + "She had no history of other cardiovascular or cerebrovascular risk factors.", + "She had no history of allergic diseases including asthma, allergic rhinitis, or urticarial.", + "She had no family history of autoimmune diseases.", + "PTU was initially started at 300 mg/day.", + "PTU was decreased to 100 mg/day once the euthyroid status was obtained.", + "In the fourth year of treatment, the patient started NSAID treatment for arthralgia.", + "In the fifth year of treatment, she developed recurrent cough and expectoration with malaise and asthenia.", + "She denied any experience of a rash, weight loss, or myalgia.", + "After 2 months of ineffective treatment with antibiotics, the patient developed hemoptysis and fever.", + "Chest CT showed diffuse alveolar infiltrates.", + "Pneumonia was considered.", + "Moxifloxacin was added to treat the bacterial infection.", + "Two weeks later, the patient still had fever, cough, and hemoptysis.", + "Repeat CT scan showed much more severe lesions with diffuse, bilateral, predominantly lower lobe nodular infiltrates and ground-glass opacity.", + "A diffuse segmental hemorrhage was noted on bronchoscopy.", + "Bronchial lavage fluid revealed 98% macrophages with iron staining positive for siderophages.", + "Culture findings were negative.", + "Free triiodothyronine was 2.18 pg/mL.", + "Free thyroxine was 0.98 ng/dL.", + "Thyroid stimulating hormone was 1.05 uIU/mL.", + "Thyroglobulin was 0.5 ng/mL.", + "Thyroglobulin antibody was > 4000 IU/mL.", + "Antithyroid peroxidase antibody was 256.4 IU/mL.", + "Erythrocyte sedimentation rate increased from 80 to 112 mm/h.", + "C-reactive protein was 39 mg/L.", + "Enzyme-linked immunosorbent assays were positive for MPO-ANCA and PR3-ANCA.", + "Immunofluorescent assays were positive for p-ANCA and c-ANCA.", + "Hemoglobin decreased from 123 g/L to 89 g/L.", + "D-dimer was 1.11 mg/L.", + "Liver and kidney functions were normal.", + "Antinuclear antibody, anti-extractable nuclear antigen, and anti-double-stranded DNA were not detected.", + "Pulmonary function tests were normal.", + "Abdominal ultrasonography and cerebral magnetic resonance imaging were unremarkable.", + "Thyroid ultrasonography showed a diffusely enlarged thyroid gland with hypervascularity.", + "The patient was diagnosed with PTU-induced ANCA-positive pulmonary vasculitis with diffuse alveolar hemorrhage.", + "PTU was discontinued promptly.", + "Intravenous methylprednisolone (80 mg/day) was initiated.", + "Three days later, the steroid dose was changed to 40 mg/day.", + "One week later, the therapy was changed to oral prednisolone.", + "The steroid dose was tapered over the next 12 weeks.", + "There was significant improvement in respiratory symptoms and fever 1 week after the start of prednisolone treatment.", + "Antithyroid antibody titers and ESR decreased markedly.", + "Approximately 1 month after observation, the serum was tested negative for ANCA.", + "ESR and HGB level were normal.", + "Chest CT indicated restoration of the lungs.", + "Chest CT showed rapid improvement in the pulmonary pathology.", + "Bronchoscopy confirmed almost complete recovery in the parenchyma.", + "After 6 months of follow-up, the patient was asymptomatic.", + "At 3 months of follow-up, ANCA was negative.", + "Whole blood and thyroid function tests revealed normal ESR, CRP, and D-dimer levels.", + "The steroid dose was tapered.", + "At the 6-month follow-up, steroids were discontinued.", + "ANCA remained negative.", + "The patient’s condition remains stable." + ], + "summary": "A 43-year-old woman with Graves' disease developed pulmonary vasculitis and diffuse alveolar hemorrhage (DAH) associated with ANCA against myeloperoxidase and proteinase-3 that was confirmed by computed tomography (CT) and bronchoscopy and treated with PTU. The symptoms and signs of alveolar hemorrhage were rapidly resolved after PTU withdrawal and treatment with corticosteroids. After 6 months of follow-up, the patient maintained complete ANCA-negative clinical remission status, as confirmed by normal CT and bronchoscopy findings. To our knowledge, this is the first documented case of bronchoscopic comparison of PTU-induced DAH before and after steroid treatment.", + "summary_subclaims": [ + "The patient is a 43-year-old woman with Graves' disease.", + "The patient developed pulmonary vasculitis and diffuse alveolar hemorrhage.", + "The patient had ANCA against myeloperoxidase and proteinase-3.", + "Computed tomography confirmed the diagnosis.", + "Bronchoscopy confirmed the diagnosis.", + "The patient was treated with PTU.", + "The symptoms and signs of alveolar hemorrhage were rapidly resolved after PTU withdrawal.", + "The patient was treated with corticosteroids.", + "After 6 months of follow-up, the patient maintained complete ANCA-negative clinical remission.", + "Normal CT findings confirmed remission.", + "Normal bronchoscopy findings confirmed remission.", + "This is the first documented case of bronchoscopic comparison of PTU-induced DAH before and after steroid treatment." + ] + }, + { + "id": "multiclinsum_test_116_en.txt", + "fulltext": "A 29-year-old female has had asymptomatic, slightly erythematous, and hypopigmented pityriasis versicolor-like lesions on her face, neck, trunk, and extremities since the age of five as well as multiple brownish-black, hyperkeratotic, papular plaque, wart-like lesions on the extremities. The lesions progressively increased in number and size with age . No abnormalities were observed upon examination of the hair, nails, mucosal membranes, and other systems, including abdominal echography and chest X-ray. Histopathology of a flat wart-like lesion showed marked hyperkeratosis, mild acanthosis, and the presence of distinct homogeneous intracytoplasmic inclusion bodies in the large clear cells of the epidermis . Additional systemic examinations and laboratory investigations, including an HIV test, were all normal. Topical 5-fluorouracil (5-FU) and imiquimod 5% cream were applied to the small pityriatic or flat wart-like lesions for three days per week at Jikei University School Hospital and Nippon Medical School Hospital. The lesions gradually decreased in size and number. She has been applying ultraviolet (UV) blocker most days and is being followed by Nippon Medical School Hospital.", + "fulltext_subclaims": [ + "The patient is a 29-year-old female.", + "She has had asymptomatic, slightly erythematous, and hypopigmented pityriasis versicolor-like lesions on her face, neck, trunk, and extremities since the age of five.", + "She has multiple brownish-black, hyperkeratotic, papular plaque, wart-like lesions on the extremities.", + "The lesions progressively increased in number and size with age.", + "No abnormalities were observed upon examination of the hair, nails, mucosal membranes, and other systems.", + "Histopathology of a flat wart-like lesion showed marked hyperkeratosis, mild acanthosis, and the presence of distinct homogeneous intracytoplasmic inclusion bodies in the large clear cells of the epidermis.", + "Additional systemic examinations and laboratory investigations, including an HIV test, were all normal.", + "Topical 5-fluorouracil (5-FU) and imiquimod 5% cream were applied to the small pityriatic or flat wart-like lesions for three days per week.", + "The lesions gradually decreased in size and number.", + "She has been applying ultraviolet (UV) blocker most days.", + "She is being followed by Nippon Medical School Hospital." + ], + "summary": "We report a case of two sisters with clinically epidermodysplasia verruciformis specific lesions on the face, neck, trunk, and extremities. PCR analysis indicated the presence of human papillomavirus type 5 in the lesions. Electron microscopic examination showed viral-like particles in keratinocyte nuclei and the stratum corneum of the epidermodysplasia verruciformis lesions. In addition, we examined the EVER1 and EVER2 genes using eight different primer pairs without finding any nonsense or frameshift mutations in the gDNA from lymphocytes of the elder sister.", + "summary_subclaims": [ + "The two sisters had clinically epidermodysplasia verruciformis specific lesions on the face, neck, trunk, and extremities.", + "PCR analysis indicated the presence of human papillomavirus type 5 in the lesions.", + "Electron microscopic examination showed viral-like particles in keratinocyte nuclei and the stratum corneum of the epidermodysplasia verruciformis lesions.", + "The EVER1 and EVER2 genes were examined using eight different primer pairs.", + "No nonsense or frameshift mutations were found in the gDNA from lymphocytes of the elder sister." + ] + }, + { + "id": "multiclinsum_test_2429_en.txt", + "fulltext": "A five year old female presented, shortly after migration from Africa, with chronic scalp infection and otitis media. She was noted to have symptomatic hyperglycaemia, with a history dating back possibly to two years of age. She was observed to have several cutaneous and facial features typical of the RMS phenotype .\nBiochemical insulin resistance was documented, with elevated fasting plasma insulin level of 1836 pmol/L (normal laboratory value: 9–80 pmol/L). At age six, diabetes mellitus was diagnosed with the classical pattern of daytime postprandial hyperglycaemia, but paradoxical nocturnal fasting hypoglycaemia. Genetic testing demonstrated a homozygote mutation at position 119 of the mature alpha subunit of the insulin receptor, but a normal beta subunit. She is of African ethnicity, and was born of a consanguineous union between first cousins. There is no other family history of insulin resistance.\nHer diabetes was initially managed with Metformin (currently 3 grams/day) followed by a brief trial of added pioglitazone. She rapidly progressed to insulin, with a current insulin requirement of 2100 units per day (>50 units/kg/day). Despite this, her glycaemic control remains suboptimal, with an HbA1c of 75 mmol/mol (9%). She has a current weight of 36 kg, height of 148 cm (Z score −1.1) and BMI of 16.6 kg/m2.\nEnlarged kidneys were noted from six years of age. Ultrasonography revealed persistent renal sizes greater than two standard deviations for her age (11 cm diameter left, 10 cm diameter right), with poorly defined medullary renal pyramids, loss of normal cortico-medullary differentiation, and a mildly dilated right collecting system. There were no renal cysts or duplex system. Nephrocalcinosis was identified, and appropriate biochemical studies were done, revealing hypercalciuria . At age of eight years a mercaptoacetyl triglycine MAG 3 renogram demonstrated normal function bilaterally with an effective renal plasma flow (ERPF) from right kidney of 379 mL/min and left kidney of 404 mL/min (normal ERPF>300 ml/min).\nAt the age of eleven years she presented with recurrent left flank pain, associated microscopic haematuria, and albuminuria on dipstick examination. There were no features to suggest an infective or traumatic aetiology to her symptoms. She was pre-pubertal. Ultrasonography showed a right kidney of 12.3 cm, left kidney of 13.2 cm, with multiple bilateral renal calculi, the largest 10mm in diameter. The right renal pelvis was dilated (1.2 cm), and a simple 10 mm cyst seen in the left kidney. The bladder was normal. A CT urogram revealed a 2 mm calcification seen to the left of the true renal pelvis, suggestive of an intraluminal ureteric calculus. Intravenous pyelogram further demonstrated paintbrush-like appearances of the renal pyramids, consistent with MSK . The patient had the most severe form of MSK, grade 4, with involvement of all the calyces in both kidneys .\nHer nephrocalcinosis was actively managed by optimising fluid intake and a trial of thiazide diuretic. Treatment was ceased at 3 months, at the request of the family as she remained asymptomatic from her nephrocalcinosis. No further acute episodes of nephrocalcinosis or pain have recurred.", + "fulltext_subclaims": [ + "The patient is a five year old female.", + "She presented with chronic scalp infection and otitis media.", + "She was noted to have symptomatic hyperglycaemia.", + "Her history of hyperglycaemia dates back possibly to two years of age.", + "She was observed to have several cutaneous and facial features typical of the RMS phenotype.", + "Biochemical insulin resistance was documented.", + "Her fasting plasma insulin level was 1836 pmol/L.", + "The normal laboratory value for fasting plasma insulin is 9–80 pmol/L.", + "At age six, diabetes mellitus was diagnosed.", + "The diabetes had the classical pattern of daytime postprandial hyperglycaemia.", + "There was paradoxical nocturnal fasting hypoglycaemia.", + "Genetic testing demonstrated a homozygote mutation at position 119 of the mature alpha subunit of the insulin receptor.", + "The beta subunit was normal.", + "She is of African ethnicity.", + "She was born of a consanguineous union between first cousins.", + "There is no other family history of insulin resistance.", + "Her diabetes was initially managed with Metformin.", + "She is currently taking 3 grams/day of Metformin.", + "She had a brief trial of added pioglitazone.", + "She rapidly progressed to insulin.", + "Her current insulin requirement is 2100 units per day.", + "Her current insulin requirement is greater than 50 units/kg/day.", + "Her glycaemic control remains suboptimal.", + "Her HbA1c is 75 mmol/mol (9%).", + "Her current weight is 36 kg.", + "Her current height is 148 cm.", + "Her height Z score is −1.1.", + "Her BMI is 16.6 kg/m2.", + "Enlarged kidneys were noted from six years of age.", + "Ultrasonography revealed persistent renal sizes greater than two standard deviations for her age.", + "The left kidney had a diameter of 11 cm.", + "The right kidney had a diameter of 10 cm.", + "There was loss of normal cortico-medullary differentiation.", + "A mildly dilated right collecting system was noted.", + "There were no renal cysts.", + "There was no duplex system.", + "Nephrocalcinosis was identified.", + "Appropriate biochemical studies were done.", + "Hypercalciuria was revealed.", + "At age eight, a MAG 3 renogram demonstrated normal function bilaterally.", + "The right kidney had an effective renal plasma flow of 379 mL/min.", + "The left kidney had an effective renal plasma flow of 404 mL/min.", + "The normal effective renal plasma flow is greater than 300 mL/min.", + "At age eleven, she presented with recurrent left flank pain.", + "She had microscopic haematuria.", + "She had albuminuria on dipstick examination.", + "There were no features to suggest an infective aetiology.", + "There were no features to suggest a traumatic aetiology.", + "She was pre-pubertal.", + "Ultrasonography showed a right kidney of 12.3 cm.", + "Ultrasonography showed a left kidney of 13.2 cm.", + "Multiple bilateral renal calculi were noted.", + "The largest renal calculus was 10 mm in diameter.", + "The right renal pelvis was dilated (1.2 cm).", + "A simple 10 mm cyst was seen in the left kidney.", + "A CT urogram revealed a 2 mm calcification to the left of the true renal pelvis.", + "The calcification was suggestive of an intraluminal ureteric calculus.", + "An intravenous pyelogram demonstrated paintbrush-like appearances of the renal pyramids.", + "The appearances were consistent with MSK.", + "The patient had the most severe form of MSK, grade 4.", + "All the calyces in both kidneys were involved.", + "Her nephrocalcinosis was actively managed by optimising fluid intake.", + "A trial of thiazide diuretic was done.", + "Treatment was ceased at 3 months.", + "The family requested to cease treatment.", + "She remained asymptomatic from her nephrocalcinosis.", + "No further acute episodes of nephrocalcinosis or pain have recurred." + ], + "summary": "We report a case of a 13 year old African female with RMS, severe insulin resistance, and a cluster of renal pathologies including nephromegaly, nephrolithiasis, hydronephrosis, and medullary sponge kidney.", + "summary_subclaims": [ + "The patient is a 13 year old African female.", + "The patient has RMS.", + "The patient has severe insulin resistance.", + "The patient has nephromegaly.", + "The patient has nephrolithiasis.", + "The patient has hydronephrosis.", + "The patient has medullary sponge kidney." + ] + }, + { + "id": "multiclinsum_test_464_en.txt", + "fulltext": "A 24-month-old female with a 2-month history of psychomotor retardation, weight loss, and unremarkable medical history was admitted to our institution. She presented horizontal nystagmus without sensory nor motor deficits. Physical examination revealed mild confusion and a cutaneous fistula in the mid-occipital region. The fistula appeared to communicate with intracranial space. Emergency CT scan [; blue arrow] and brain MRI showed a cystic infratentorial mass with ring enhancement of the cystic walls. In the suspect of intracranial abscess, treatment with ceftriaxone 75 mg/kg was administered every 24 h.\nDuring preparation for surgery, a 5 mm non-purulent subcutaneous nodule with skin fistula was seen . A suboccipital craniotomy was performed. The cerebellar abscess was evacuated, followed by excision of the entire capsule . Total resection of a 3 cm whitish, midline, encapsulated, and hairy cystic mass was performed. The cyst was adherent to the dura and to the confluence of sinuses .\nBacterial investigation revealed methicillin-sensitive Staphylococcus aureus. Histological examination confirmed the diagnosis of dermoid tumor . Therefore, antibiotic treatment was switched to Ampicillin IV 50 mg/kg every 6 h and was administered for 7 weeks after surgery.\nThe patient’s physical condition and neurological symptoms improved rapidly. After 15 days, she was discharged without any deficit. At a 36-month follow-up, there was no evidence of recurrence .", + "fulltext_subclaims": [ + "The patient is a 24-month-old female.", + "The patient had a 2-month history of psychomotor retardation.", + "The patient had a 2-month history of weight loss.", + "The patient had no prior medical history.", + "The patient presented with horizontal nystagmus.", + "The patient had no sensory deficits.", + "The patient had no motor deficits.", + "Physical examination revealed mild confusion.", + "A cutaneous fistula was found in the mid-occipital region.", + "The fistula appeared to communicate with intracranial space.", + "Emergency CT scan showed a cystic infratentorial mass.", + "The cystic walls showed ring enhancement.", + "Intracranial abscess was suspected.", + "Ceftriaxone 75 mg/kg was administered every 24 h.", + "A 5 mm non-purulent subcutaneous nodule with skin fistula was seen.", + "A suboccipital craniotomy was performed.", + "The cerebellar abscess was evacuated.", + "The entire capsule was excised.", + "A 3 cm whitish, midline, encapsulated, and hairy cystic mass was resected.", + "The cyst was adherent to the dura.", + "The cyst was adherent to the confluence of sinuses.", + "Bacterial investigation revealed methicillin-sensitive Staphylococcus aureus.", + "Histological examination confirmed the diagnosis of dermoid tumor.", + "Antibiotic treatment was switched to Ampicillin IV 50 mg/kg every 6 h.", + "Antibiotic treatment was administered for 7 weeks after surgery.", + "The patient’s physical condition improved rapidly.", + "Neurological symptoms improved rapidly.", + "The patient was discharged after 15 days.", + "The patient had no deficits at discharge.", + "At 36-month follow-up, there was no evidence of recurrence." + ], + "summary": "A 24-month-old girl was admitted to our institution with a cutaneous fistula in the midline of the occipital region. Brain imaging showed an infratentorial intradiploic cyst with peripheral enhancement to contrast medium. The mass showed hyperintensity on T1-weighted sequences, with the lower signal on T2-weighted images. A suboccipital craniotomy was performed with evacuation of the abscess and excision of the capsule. Contextually a 3 cm whitish and encapsulated cystic mass with hair component was extracted. Histology confirmed the diagnosis of abscess associated with dermal cyst and dermal sinus. The patient condition improved and 15 days after excision, was discharged. The postoperative MRI showed total removal of the lesion. A 36-month follow-up highlighted no evidence of recurrence.", + "summary_subclaims": [ + "A 24-month-old girl was admitted to our institution with a cutaneous fistula in the midline of the occipital region.", + "Brain imaging showed an infratentorial intradiploic cyst with peripheral enhancement to contrast medium.", + "The mass showed hyperintensity on T1-weighted sequences.", + "The mass showed lower signal on T2-weighted images.", + "A suboccipital craniotomy was performed with evacuation of the abscess and excision of the capsule.", + "A 3 cm whitish and encapsulated cystic mass with hair component was extracted.", + "Histology confirmed the diagnosis of abscess associated with dermal cyst and dermal sinus.", + "The patient condition improved and 15 days after excision, was discharged.", + "The postoperative MRI showed total removal of the lesion.", + "A 36-month follow-up highlighted no evidence of recurrence." + ] + }, + { + "id": "multiclinsum_test_1436_en.txt", + "fulltext": "A 31-year-old black Congolese female patient, P3G3, who had a pregnancy of 38 weeks and four days, was transferred from a district hospital to a tertiary facility in Kinshasa, Democratic Republic of Congo, for severe preeclampsia with acute on chronic fetal distress. Her past medical history was notable for eclampsia during her first pregnancy in 2011 and preeclampsia in 2013 during her second pregnancy. She had had two cesarean sections for her pregnancies, and she had her antenatal care for her third pregnancy at a referral hospital. She was diagnosed with preeclampsia during her third pregnancy for which she received 250 mg alpha-methyl-dopa twice a day. ​​During the 30th week of gestation, the patient’s systolic blood pressure became labile, oscillating between 140 and 150 mmHg, despite her antihypertension medication. The patient consulted at a district hospital where she underwent a fetal wellbeing ultrasound which did not find anomalies.\nThe patient was the 7th of 9 children, and her father was hypertensive. She weighed 72 kg for 155 cm, and upon arrival at the authors’ hospital, her blood pressure was 217/152 mmHg. Her heart rate was 101 bpm, her respiratory rate was 24 cpm, and SpO2 was 96% free air. The patient was in pain, she was lucid and coherent, her palpebral conjunctivae were colored, and she had bilateral pitting edema. The fundus height was at 30 cm, the presentation was cephalic, the fetus was bradycardic at 88 bpm, and there were no signs of genital bleeding. The cervix was median, soft, 80% effaced with a 2 cm dilation. Urine deep stick revealed 3+ proteinuria. She had 1.5 mg/dL of creatinine (normal: 0.5–1.5 mg/dL), 22 mg/dL of urea (normal: 10–50 mg/dL), 15,000 white blood cells/ml, 213,000 platelets/ml and 14 g/dL hemoglobin. Based on these findings, we indicated an emergency cesarean section for acute fetal distress, which resulted in the extraction of a dead infant.\nPostoperative suites were marked on day two by decompensated anemia (hemoglobin at 7.8 mg/dL) for which the patient was transfused two units of packed red blood cells. On postoperative day three, the patient presented an abdominal effusion, exacerbation of the bilateral pitting edema, blood pressure increase, hematemesis, melena, petechiae, hematuria, and oliguria. Her blood pressure was 215/120 mmHg and she had signs of renal failure (creatinine = 6.9 mg/dL (normal: 0.84–1.21 mg/dL); urea 132.5 mg/dL (normal: 5–20 mg/dL); hyperkalemia at 6.4 mmol/L (normal: 3.5–5 mmol/L); hyponatremia 109 mmol/L (normal: 136–145 mmol/L); hypocalcemia 0.88 mmol/L (normal: 1.12–1.32 mmol/L)), and signs of hepatic failure (AST 135 IU/L, normal: < 33 IU/L; ALT 325 IU/L, normal: < 33 IU/L; prothrombin ratio 100% (normal: 80–110%). PTT was 39 s (normal: 24–35 s), LDH was 1398 IU/L (normal: 120–280 IU/L), and total bilirubin was 0.35 mg/dL (normal: 0-1 mg/dL)). She equally had neutrophilic leukocytosis at 22,180 cells/mm3 and low platelets at 44,000 cells/mm3. Additionally, schistocytes were identified in the peripheral thin smear.\nThe team excluded TTP and HELLP syndrome as possible causes of the postpartum microangiopathic hemolytic anemia (MAHA). This decision was based on the history, clinical presentation, and laboratory findings. Atypical hemolytic uremic syndrome was retained as the final diagnosis, and in the absence of anti-complement therapy, the patient underwent four sessions of hemodialysis. Hypertension was treated with Nicardipine, 5 mg/hr. IV with a 2.5 mg/hr. increase every 15 min without exceeding 15 mg/hr., and the goal was to lower the systolic blood pressure below 160 mmHg. Hyperkalemia was corrected with insulin and glucose (10 units of insulin dose with 25 g of glucose per each 1 mmol/L of potassium above the normal). A favorable clinical and biologic evolution was observed, and the patient was released for outpatient follow-up on postoperative day 18 .\nLaboratory tests could not be obtained more frequently due to their financial burden to the patient and her immediate family. The patient had a normal kidney function at postoperative day 160 (urea 24.2 g/dL, creatinine 0.8 mg/dL) and postoperative day 202 (urea 16.9 g/dL, creatinine 0.8 mg/dL). She did not present new episodes of microangiopathic hemolytic anemia.", + "fulltext_subclaims": [ + "The patient was a 31-year-old black Congolese female.", + "She was P3G3.", + "She had a pregnancy of 38 weeks and four days.", + "She was transferred to a tertiary facility in Kinshasa.", + "She had severe preeclampsia.", + "She had acute on chronic fetal distress.", + "She had eclampsia during her first pregnancy in 2011.", + "She had preeclampsia during her second pregnancy in 2013.", + "She had two cesarean sections.", + "She had antenatal care for her third pregnancy at a referral hospital.", + "She was diagnosed with preeclampsia during her third pregnancy.", + "She received 250 mg alpha-methyl-dopa twice a day.", + "During the 30th week of gestation, her systolic blood pressure oscillated between 140 and 150 mmHg.", + "She consulted at a district hospital.", + "She underwent a fetal wellbeing ultrasound.", + "The ultrasound did not find anomalies.", + "She was the 7th of 9 children.", + "Her father was hypertensive.", + "She weighed 72 kg for 155 cm.", + "Upon arrival at the authors’ hospital, her blood pressure was 217/152 mmHg.", + "Her heart rate was 101 bpm.", + "Her respiratory rate was 24 cpm.", + "Her SpO2 was 96% free air.", + "She was in pain.", + "She was lucid and coherent.", + "She had bilateral pitting edema.", + "The fundus height was at 30 cm.", + "The presentation was cephalic.", + "The fetus was bradycardic at 88 bpm.", + "There were no signs of genital bleeding.", + "The cervix was median, soft, 80% effaced with a 2 cm dilation.", + "Urine deep stick revealed 3+ proteinuria.", + "She had 1.5 mg/dL of creatinine.", + "She had 22 mg/dL of urea.", + "She had 15,000 white blood cells/ml.", + "She had 213,000 platelets/ml.", + "She had 14 g/dL hemoglobin.", + "An emergency cesarean section was indicated for acute fetal distress.", + "The cesarean section resulted in the extraction of a dead infant.", + "On postoperative day two, she had decompensated anemia (hemoglobin at 7.8 mg/dL).", + "She was transfused two units of packed red blood cells.", + "On postoperative day three, she presented an abdominal effusion.", + "She had exacerbation of bilateral pitting edema.", + "She had blood pressure increase.", + "She had hematemesis.", + "She had melena.", + "She had petechiae.", + "She had hematuria.", + "She had oliguria.", + "Her blood pressure was 215/120 mmHg.", + "She had signs of renal failure.", + "She had signs of hepatic failure.", + "She had neutrophilic leukocytosis at 22,180 cells/mm3.", + "She had low platelets at 44,000 cells/mm3.", + "Schistocytes were identified in the peripheral thin smear.", + "The team excluded TTP and HELLP syndrome as possible causes of the postpartum microangiopathic hemolytic anemia.", + "Atypical hemolytic uremic syndrome was retained as the final diagnosis.", + "The patient underwent four sessions of hemodialysis.", + "Hypertension was treated with Nicardipine.", + "Hyperkalemia was corrected with insulin and glucose.", + "A favorable clinical and biologic evolution was observed.", + "The patient was released for outpatient follow-up on postoperative day 18.", + "Laboratory tests could not be obtained more frequently due to their financial burden.", + "She had normal kidney function at postoperative day 160.", + "She had normal kidney function at postoperative day 202.", + "She did not present new episodes of microangiopathic hemolytic anemia." + ], + "summary": "A 31-year old P3G3 patient presented at 38 weeks with high blood pressure, bilateral pitting edema, and a low fetal heart rate. A cesarean section was performed to extract the fetus. On postoperative day 2, the suites were marked by anemia, low platelet count, acute kidney injury, declining liver function, and the presence of schistocytes on the peripheral thin smear. The patient was lucid, coherent, and presented no neurological deficits. The ADAMTS13 test and anti-complement therapy were not readily available, so the team made a presumptive diagnosis of aHUS based on the history, clinical presentation, and standard laboratory results. Due to a lack of anticomplement therapy, the patient was prescribed four sessions of hemodialysis. The renal function and platelet count gradually increased, and the patient was discharged on postoperative day 18. The patient was followed for over a year and did not present relapses of thrombocytopenia or microangiopathic hemolytic anemia.", + "summary_subclaims": [ + "The patient was a 31-year old P3G3.", + "The patient presented at 38 weeks with high blood pressure.", + "The patient had bilateral pitting edema.", + "The patient had a low fetal heart rate.", + "A cesarean section was performed to extract the fetus.", + "On postoperative day 2, the patient had anemia.", + "On postoperative day 2, the patient had a low platelet count.", + "On postoperative day 2, the patient had acute kidney injury.", + "On postoperative day 2, the patient had declining liver function.", + "On postoperative day 2, schistocytes were present on the peripheral thin smear.", + "The patient was lucid.", + "The patient was coherent.", + "The patient presented no neurological deficits.", + "The ADAMTS13 test was not readily available.", + "Anti-complement therapy was not readily available.", + "The team made a presumptive diagnosis of aHUS.", + "The patient was prescribed four sessions of hemodialysis.", + "The renal function gradually increased.", + "The platelet count gradually increased.", + "The patient was discharged on postoperative day 18.", + "The patient was followed for over a year.", + "The patient did not present relapses of thrombocytopenia.", + "The patient did not present relapses of microangiopathic hemolytic anemia." + ] + }, + { + "id": "multiclinsum_test_870_en.txt", + "fulltext": "The patient was a six-month-old female with a red patch on her back found more than 20 days after birth. Later, a gradually enlarged mass was found over the surrounding skin, which slowly increased in size as the child grew, measuring approximately 11 cm × 6 cm . No urinary dribbling, lower extremity deformity or scoliosis, anorectal malformation or sphincter dysfunction was observed. The infant was uncooperative for neurological examination and no signs of lower limb paresis or paralysis were found. Ultrasonography revealed an infantile hemangioma. Complete blood count showed white blood cell, red blood cell, hemoglobin, and platelet levels of 7.62 × 109/L, 3.98 × 1012/L, 112 g/L, and 436 × 109/L, respectively. On laboratory tests, no significant abnormality was found. A small portion of the tumor was taken for histopathological examination, and lipofibromatosis was suspected. Upon consulting at the pathology department of another hospital, fibrous hamartoma of infancy was suspected. The mass was subsequently excised completely under general anesthesia with preoperative blood preparation . A fusiform incision was made 0.5 cm along the outer edge of the tumor, after which, both sides of the incision were widely free to the outer edge and sutured layer by layer. On pathological examination, spindle cell tumor was confirmed. The tumor consisted of adipose tissue and fusiform fibroblasts, which tended to be lipofibromatosis (Observed under the microscope OLYMPUS CX31, Olympus Corporation, Japan; photographed by the software Oplenic Pro, Hangzhou Chroma Optronics CO., LTD, China). Immunohistochemistry results included the following: CD99 (focal +), smooth muscle actin (SMA) (-), ki67 (+5-15%), CD34 (++++) , CD31 (-), ERG (-), SOX10(-), S-100 (-) , BCL2 (-), P1H3 (+8%), P53 (-), Desmin (-) Myogenin (-), MyoD1 (-), and pan-TRK (-) (Observed under the microscope Pannoramic MIDI, 3DHISTECH Ltd, Hungary; photographed by the software Pannoramic Scanner, 3DHISTECH Ltd, Hungary). Genetic testing showed no positive mutations in exons 18, 19, 20, and 21 of the EGFR gene. The author detected the NTRK1 gene by FISH and found no fusion or rearrangement of the NTRK1 gene . (Observed under the microscope Pannoramic MIDI, 3DHISTECH Ltd, Hungary; photographed by the software Pannoramic Scanner, 3DHISTECH Ltd, Hungary).The patient was eventually diagnosed with lipofibromatosis. One year later, the patient was reassessed, and no signs of recurrence were found , with scarring of the incision remnants. The scar will be repaired after the child grows up, and follow-up is continuing.", + "fulltext_subclaims": [ + "The patient was a six-month-old female.", + "The patient had a red patch on her back found more than 20 days after birth.", + "A gradually enlarged mass was found over the surrounding skin.", + "The mass measured approximately 11 cm × 6 cm.", + "No urinary dribbling, lower extremity deformity or scoliosis, anorectal malformation or sphincter dysfunction was observed.", + "The infant was uncooperative for neurological examination.", + "No signs of lower limb paresis or paralysis were found.", + "Ultrasonography revealed an infantile hemangioma.", + "Complete blood count showed white blood cell levels of 7.62 × 109/L.", + "Complete blood count showed red blood cell levels of 3.98 × 1012/L.", + "Complete blood count showed hemoglobin levels of 112 g/L.", + "Complete blood count showed platelet levels of 436 × 109/L.", + "On laboratory tests, no significant abnormality was found.", + "A small portion of the tumor was taken for histopathological examination.", + "Lipofibromatosis was suspected.", + "Upon consulting at the pathology department of another hospital, fibrous hamartoma of infancy was suspected.", + "The mass was subsequently excised completely under general anesthesia with preoperative blood preparation.", + "A fusiform incision was made 0.5 cm along the outer edge of the tumor.", + "Both sides of the incision were widely free to the outer edge and sutured layer by layer.", + "On pathological examination, spindle cell tumor was confirmed.", + "The tumor consisted of adipose tissue and fusiform fibroblasts.", + "The tumor tended to be lipofibromatosis.", + "CD99 was focal +.", + "Smooth muscle actin (SMA) was -.", + "Ki67 was +5-15%.", + "CD34 was ++++.", + "CD31 was -.", + "ERG was -.", + "SOX10 was -.", + "S-100 was -.", + "BCL2 was -.", + "P1H3 was +8%.", + "P53 was -.", + "Desmin was -.", + "Myogenin was -.", + "MyoD1 was -.", + "Pan-TRK was -.", + "Genetic testing showed no positive mutations in exons 18, 19, 20, and 21 of the EGFR gene.", + "The author detected the NTRK1 gene by FISH and found no fusion or rearrangement of the NTRK1 gene.", + "The patient was eventually diagnosed with lipofibromatosis.", + "One year later, the patient was reassessed, and no signs of recurrence were found.", + "The incision remnants were scarred.", + "The scar will be repaired after the child grows up.", + "Follow-up is continuing." + ], + "summary": "This is a case report of a patient with a giant lipofibromatosis on the back that resembles an infantile hemangioma, which posed great difficulty in diagnosis due to atypical clinical manifestations. After the postoperative pathological and immunohistochemical examination and fluorescence in situ hybridization, the patient was finally diagnosed with lipofibromatosis.", + "summary_subclaims": [ + "This is a case report of a patient with a giant lipofibromatosis on the back.", + "The lipofibromatosis resembled an infantile hemangioma.", + "The diagnosis posed great difficulty due to atypical clinical manifestations.", + "The patient underwent postoperative pathological and immunohistochemical examination.", + "Fluorescence in situ hybridization was performed.", + "The patient was finally diagnosed with lipofibromatosis." + ] + }, + { + "id": "multiclinsum_test_2386_en.txt", + "fulltext": "We report a case of 46-year-old male complaining of abdominal pain and obstructive jaundice. He was referred to the digestive surgeon at Fatmawati Central General Hospital. The physical examination revealed that the abdomen was distended with palpably enlarged spleen and liver. An abdominal contrast computed tomography (CT) scan found lobulated masses in the duodenal and ampulla of vater projection. Surgical intervention was decided and the patient was admitted to the intensive care unit (ICU) after a total pancreato-splenectomy due to a stage IIIb duodenal tumor.\nDuring the preoperative assessment, we concluded that this patient was high risk due to anemia, obstructive jaundice, and decreased liver function. Intraoperatively, massive surgical bleeding (2500 cc) was sustained due to extensive tumor resection, and thus massive blood product transfusion was necessary.\nUpon arrival at the ICU, our patient had decreased urine output. Therefore, we had to increase the vasopressor dose to 0.3 µg/kg/minute to maintain the mean arterial pressure above 65 mmHg and systolic blood pressure above 95 mmHg. Laboratory examination revealed a lactate level of 5.8 mmol/L, C-reactive protein (CRP) level of 30 mg/dL, white blood cell counts of 26,700/μL, and procalcitonin level of > 32 ng/mL. These findings showed that the patient had a systemic inflammation response syndrome (SIRS) due to the surgery. Furthermore, 12 hours after the surgery, he showed signs of AKI, including urine production of < 0.3 cc/kg/hour. Hyperglycemia was another problem observed in the patient, with the highest glucose level recorded at 511 mg/dL within 3 hours after the surgery. Glucose management therapy was started with an insulin infusion drip of up to 7 IU/hour.\nWe decided to initiate early continuous renal replacement therapy (CRRT) for this patient. The CRRT was initiated within 24 hour following the diagnosis of postoperative AKI on the basis of Kidney Disease Improving Global Outcome (KDIGO) criteria stage 2. CRRT was conducted using the continuous veno-venous hemofiltration (CVVH) method. The effluent dose was 27 cc/kg/hour with 0 cc fluid removal. After 3 hours of CVVH initiation, the patient showed signs of improvement. His urine output increased to 0.5–0.6 cc/kg/hour, and the vasopressor dose was quickly tapered. We decided to administer furosemide infusion within 18 hours after CVVH, and the patient’s urine output increased to 1–4 cc/kg/hour .\nThe patient’s inflammation was assessed on the basis of his CRP levels. On day 1 after the surgery, the patient’s CRP level was 35 mg/dL. Following the initiation of CVVH on the third postoperative day, his CRP level decreased significantly to 15.1 mg/dL. The inflammation was significantly reduced as the CVVH continued . After the initiation of CVVH, the patient’s blood glucose was controlled and the insulin infusion drip rate was reduced to 0.3 U/hour .\nOn the second postoperative day, the patient’s white blood cell count and procalcitonin level increased, indicating an ongoing infection. We changed the antibiotic course and administered an empirical broad-spectrum antibiotic instead, with 3 × 2 g intravenous meropenem. We observed a good clinical response after the CRRT was initiated . Urine output was increasing and we could reduce the norepinephrine dose. The CRRT was stopped on the third postoperative day and furosemide was started at 1 mg/hour for renal support.\nOn the fourth postoperative day, the patient was alert and cooperative with minimal ventilatory and hemodynamic support. The patient was extubated and respiratory support was provided with a nasal cannula .", + "fulltext_subclaims": [ + "The patient was a 46-year-old male.", + "The patient complained of abdominal pain and obstructive jaundice.", + "The patient was referred to the digestive surgeon at Fatmawati Central General Hospital.", + "The physical examination revealed that the abdomen was distended.", + "The physical examination revealed a palpably enlarged spleen.", + "The physical examination revealed a palpably enlarged liver.", + "An abdominal contrast CT scan found lobulated masses in the duodenal and ampulla of vater projection.", + "Surgical intervention was decided.", + "The patient was admitted to the ICU after a total pancreato-splenectomy.", + "The tumor was stage IIIb.", + "The preoperative assessment concluded that the patient was high risk.", + "The high risk was due to anemia, obstructive jaundice, and decreased liver function.", + "Intraoperatively, massive surgical bleeding (2500 cc) was sustained.", + "Massive blood product transfusion was necessary.", + "Upon arrival at the ICU, the patient had decreased urine output.", + "The vasopressor dose was increased to 0.3 µg/kg/minute.", + "The mean arterial pressure was maintained above 65 mmHg.", + "The systolic blood pressure was maintained above 95 mmHg.", + "The lactate level was 5.8 mmol/L.", + "The CRP level was 30 mg/dL.", + "The white blood cell count was 26,700/μL.", + "The procalcitonin level was > 32 ng/mL.", + "These findings showed that the patient had systemic inflammation response syndrome (SIRS) due to the surgery.", + "The patient showed signs of AKI 12 hours after the surgery.", + "The urine production was < 0.3 cc/kg/hour.", + "The highest glucose level recorded was 511 mg/dL.", + "Glucose management therapy was started with an insulin infusion drip.", + "The insulin infusion drip rate was up to 7 IU/hour.", + "Early CRRT was initiated within 24 hours following the diagnosis of postoperative AKI.", + "The CRRT was initiated on the basis of KDIGO criteria stage 2.", + "CRRT was conducted using the CVVH method.", + "The effluent dose was 27 cc/kg/hour.", + "The fluid removal was 0 cc.", + "After 3 hours of CVVH initiation, the patient showed signs of improvement.", + "The urine output increased to 0.5–0.6 cc/kg/hour.", + "The vasopressor dose was quickly tapered.", + "Furosemide infusion was administered within 18 hours after CVVH.", + "The patient’s urine output increased to 1–4 cc/kg/hour.", + "The CRP level on day 1 after the surgery was 35 mg/dL.", + "Following the initiation of CVVH on the third postoperative day, the CRP level decreased to 15.1 mg/dL.", + "The inflammation was significantly reduced as the CVVH continued.", + "The insulin infusion drip rate was reduced to 0.3 U/hour.", + "On the second postoperative day, the white blood cell count and procalcitonin level increased.", + "The antibiotic course was changed.", + "An empirical broad-spectrum antibiotic was administered.", + "The antibiotic was 3 × 2 g intravenous meropenem.", + "A good clinical response was observed after the CRRT was initiated.", + "The CRRT was stopped on the third postoperative day.", + "Furosemide was started at 1 mg/hour.", + "On the fourth postoperative day, the patient was alert and cooperative.", + "The patient was extubated.", + "Respiratory support was provided with a nasal cannula." + ], + "summary": "Our patient was a 46-year-old male of Malay ethnicity, undergoing total pancreatectomy due to a duodenal tumor. The preoperative assessment showed that the patient was high risk. Intraoperatively, massive surgical bleeding was sustained due to extensive tumor resection; thus, massive blood product transfusion was necessary. After the surgery, the patient suffered from postoperative acute kidney injury. We performed early continuous renal replacement therapy, within 24 hours after the diagnosis of acute kidney injury. Upon completion of continuous renal replacement therapy, the patient's condition improved, and he was discharged from the intensive care unit on the sixth postoperative day.", + "summary_subclaims": [ + "The patient was a 46-year-old male of Malay ethnicity.", + "The patient underwent total pancreatectomy.", + "The total pancreatectomy was due to a duodenal tumor.", + "The preoperative assessment showed that the patient was high risk.", + "Intraoperatively, massive surgical bleeding was sustained.", + "Massive surgical bleeding was due to extensive tumor resection.", + "Massive blood product transfusion was necessary.", + "After the surgery, the patient suffered from postoperative acute kidney injury.", + "We performed early continuous renal replacement therapy.", + "The continuous renal replacement therapy was within 24 hours after the diagnosis of acute kidney injury.", + "Upon completion of continuous renal replacement therapy, the patient's condition improved.", + "The patient was discharged from the intensive care unit on the sixth postoperative day." + ] + }, + { + "id": "multiclinsum_test_1378_en.txt", + "fulltext": "A 73-year-old woman with past medical history of hypertension and rheumatoid arthritis stage 4 under regular anti-hypertension medication and long-term corticosteroid therapy, presented to us in August 2010 with the chief complaint of decline of visual acuity of her right eye and right periorbital pain for 2 months. At the beginning of the clinical course, she had brain computed tomography (CT) scan and orbit magnetic resonance imaging (MRI) done in June 2010, which disclosed a small enhancing lesion, about 1.2 cm × 1.1 cm × 1 cm in size, near the right side orbital apex and adjacent right side superior orbital fissure with mild encasement of the right optic nerve, and this lesion showed mild extension to the adjacent right side posterior ethmoid sinus [Figure , ]. She had pulse steroid therapy in ophthalmology service, but it was ineffective. On admission, her neurological examination showed that she had right eye blindness, right ptosis, right ophthmaloplegia, and tingle in the territory of ophthalmic branch of right trigeminal nerve. Repeated MRI of orbit after admission in August 2010 showed the progression of the lesion which enlarged up to 1.5 cm × 1.3 cm × 1.2 cm [Figure , ]. She underwent endoscopic endonasal transethmoid approach with the removal of the lesion on 19 August 2010 under general anesthesia. After the surgery, she recovered well and her right periorbital pain was much released. However, 5 days after surgery, she experienced a severe headache followed by loss of consciousness. After endotracheal tube intubation and resuscitation, brain CT was checked which showed diffuse high-density acute SAH in the basal cistern, pre-pontine cistern, ambient cistern, quadrigeminal cistern, cerebellomedullary cistern, and right sylvian fissure, with acute hydrocephalus . Emergent external ventricular drainage was done followed by performing CT angiography which showed several bleb-like wide base aneurysms over right supraclinoid internal carotid artery (ICA), and one aneurysm, about 4 mm in size and located at the medial side of the right supraclinoid internal carotid artery, showed extravasation of contrast medium. The dome of the ruptured aneurysm projected medially and superiorly . On the same day, the histology examination reported that the lesion was composed of many fungal septate hyphae demonstrated on both HE stain and periodic acid-Schiff (PAS) stain [Figure , ]. Fungal infection was diagnosed and the culture turned out to be Aspergillus fumigatus. Her intracranial aneurysms were probably fungal aneurysms, which are one of the sequels of central nervous system (CNS) fungal infection. Unfortunately, after the event, she remained in deep coma and finally she expired due to central failure.", + "fulltext_subclaims": [ + "The patient is a 73-year-old woman.", + "She has a past medical history of hypertension.", + "She has a past medical history of rheumatoid arthritis stage 4.", + "She is under regular anti-hypertension medication.", + "She is on long-term corticosteroid therapy.", + "She presented in August 2010 with decline of visual acuity of her right eye.", + "She presented in August 2010 with right periorbital pain for 2 months.", + "She had a brain CT scan and orbit MRI in June 2010.", + "The June 2010 imaging disclosed a small enhancing lesion near the right side orbital apex.", + "The lesion was about 1.2 cm × 1.1 cm × 1 cm in size.", + "The lesion showed mild encasement of the right optic nerve.", + "The lesion showed mild extension to the adjacent right side posterior ethmoid sinus.", + "She had pulse steroid therapy in the ophthalmology service.", + "The pulse steroid therapy was ineffective.", + "On admission, she had right eye blindness.", + "On admission, she had right ptosis.", + "On admission, she had right ophthalmoplegia.", + "On admission, she had tingle in the territory of the ophthalmic branch of the right trigeminal nerve.", + "Repeated MRI of the orbit after admission in August 2010 showed progression of the lesion.", + "The lesion enlarged to 1.5 cm × 1.3 cm × 1.2 cm.", + "She underwent endoscopic endonasal transethmoid approach with removal of the lesion on 19 August 2010.", + "After surgery, her right periorbital pain was much relieved.", + "Five days after surgery, she experienced a severe headache followed by loss of consciousness.", + "Brain CT showed diffuse high-density acute subarachnoid hemorrhage in multiple cisterns.", + "Brain CT showed acute hydrocephalus.", + "Emergent external ventricular drainage was performed.", + "CT angiography showed several bleb-like wide base aneurysms over the right supraclinoid internal carotid artery.", + "One aneurysm, about 4 mm in size, showed extravasation of contrast medium.", + "The dome of the ruptured aneurysm projected medially and superiorly.", + "Histology examination showed many fungal septate hyphae on HE stain.", + "Histology examination showed many fungal septate hyphae on PAS stain.", + "Fungal infection was diagnosed.", + "The culture turned out to be Aspergillus fumigatus.", + "Her intracranial aneurysms were probably fungal aneurysms.", + "Fungal aneurysms are one of the sequels of central nervous system fungal infection.", + "She remained in deep coma after the event.", + "She expired due to central failure." + ], + "summary": "A 73-year-old female having hypertension and rheumatoid arthritis stage 4 under long-term corticosteroid therapy presented to us with the right side orbital apex syndrome. Her magnetic resonance imaging (MRI) of orbit showed progression of a lesion at the right orbital apex and adjacent right superior orbital fissure with mild extension to the right posterior ethmoid sinus. She underwent endoscopic endonasal transethmoid approach with the removal of the lesion. The pathology showed a picture of fungal infection and the culture of the specimen proved Aspergillus fumigatus. Her postoperative course was smooth until 5 days after surgery, when she suffered a massive spontaneous subarachnoid hemorrhage resulting from a ruptured aneurysm, which was proven by computed tomography angiography (CTA) of brain. Unfortunately, she expired due to central failure.", + "summary_subclaims": [ + "The patient is a 73-year-old female.", + "She has hypertension.", + "She has rheumatoid arthritis stage 4.", + "She was under long-term corticosteroid therapy.", + "She presented with right side orbital apex syndrome.", + "Her MRI of orbit showed progression of a lesion at the right orbital apex.", + "The lesion extended to the adjacent right superior orbital fissure.", + "There was mild extension to the right posterior ethmoid sinus.", + "She underwent endoscopic endonasal transethmoid approach.", + "The lesion was removed.", + "The pathology showed a picture of fungal infection.", + "The culture of the specimen proved Aspergillus fumigatus.", + "She had a smooth postoperative course until 5 days after surgery.", + "She suffered a massive spontaneous subarachnoid hemorrhage.", + "The hemorrhage resulted from a ruptured aneurysm.", + "Computed tomography angiography of brain proved the aneurysm.", + "She expired due to central failure." + ] + }, + { + "id": "multiclinsum_test_2261_en.txt", + "fulltext": "The patient is a 15-year-old boy whose clinical history started at 5 years old. Seizures at onset were (1) imbalance and cold sensation and (2) limbs and face paresthesia followed by loss of consciousness and limbs stiffening. MRI scan showed a right parietal dysembryoplastic neuroepithelial tumor (DNET). After surgical removal, the boy was seizure free for 2 years. At 7 years old, focal seizures characterized by behavioral arrest, mental confusion, left upper limb paresthesia, and distorted voice sensations, followed by lower limb stiffening and weakness or imbalance appeared. Long-term video EEG monitoring showed background rhythm asymmetry and right centro-parieto-temporal interictal paroxysmal abnormalities. Ictal EEG highlighted large slow right parietal and temporal waves preceded by rapid activity. Seizures control lacked despite poly-antiepileptic drugs (AEDs) with valproate acid, oxcarbazepine, and clobazam. Control MRI excluded tumor regrowth showing only scar tissue on the superficial and deep-middle inferior parietal region extending to the marginal and angular gyrus, to the posterior insula, and to the inferior parietal gyrus behind rolandic cortex. Thus, the child underwent a second surgery, aided by electrocorticography (ECoG) to remove the altered sulci in the postero-medial portion of the previous surgical cavity as well as the right superior temporal gyrus. Seizure freedom was achieved for 3 years.\nNonetheless, seizure relapsed after 2 years becoming heterogeneous and multidrug-resistant. The boy experienced anesthesia and loss of tone in the left arm, twisting of the jaw to the left and dysarthria accompanied by daze, lightheadedness sometimes associated with headache and dizziness, and negative myoclonus involving the left hand. Therefore, a new pre-surgical epileptic work up was proposed.\nThe registration was made through 21 copper disc electrodes according to the International System 10-20 (band pass 1.600–70 Hz, sampling rate 512 Hz). The recording lasted 3 days and included Intermittent Light Stimulation protocol at increasing frequencies (3–50 Hz) and 5 minutes hyperventilation. Data were analyzed using Micromed System View. Interictal EEG was characterized by slow activity and spike and slow wave discharges on right central parietal regions, spreading on the posterior vertex ones. Independent and isolated spikes on right posterior temporal derivations were also observed. Three types of seizures were recorded: focal motor, characterized by discharges of spike-wave on the right parietal regions with subsequent bihemispheric diffusion; focal non-motor, characterized by delta-like slow activity; and spike-wave on the right centro-parietal regions with right hemispheric diffusion and negative myoclonus, characterized by slow wave discharges on the right parietal and frontal regions with diffusion on the contra lateral homologous regions.\nCognitive assessment was carried out using the Wechsler Intelligence Scale for Children (version IV, 2003) which highlighted a normal level (IQ 88), characterized by a disharmonic profile, in the presence of a significant difference (> 12 points) between the indices, to the detriment of the score obtained in working memory (73) and processing speed (82). Visuo-spatial memory was quite impaired (recall of Rey figure—5ds). Verbal memory tests showed normal performance in short-term recall and slight difficulty in the long-term one. Furthermore, there was a marked difficulty in lexical retrieval with a phonological facilitator and slight difficulty with a semantic facilitator. Tests performed with Developmental Neuropsychological Assessment (NEPSY-II, 2007) showed a marked deficit in sustained attention and a slight difficulty in visual-motor integration.\nA scalp hdEEG with 128 channels was performed. The registration was made through pre-assembled caps with 128 electrodes according to the 10-10 system (electrode impedances < 40 kΩ; sampling frequency 1 kHz; the vertex was used as recording reference). The recording lasted about 2 h including wake and sleep. No seizures were recorded. Offline, EEG was analyzed through the Micromed SystemView; band pass filtered between 0.1 and 100 Hz and any paroxysmal anomalies was noted. A head model was built using T1-weighted MRI and scalp electrodes were co-registered with the MRI using a template net of electrodes with standard position that was translated/rotated/dilated with personalized digitalization through scalp navigation system (XensorTM 3D Electrode Digitizer) . For the inverse solution, low resolution electromagnetic tomography (LORETA) was used through ASA® Experiment Manager® Software. Only the solution point with maximal source strength was taken into account. An interictal source was identified in the mesial part of the right superior parietal lobule. Another source, of lesser force, was found in the right frontal lobe at the level of the right prefrontal area .\nSEEG was also performed. Seven depth electrodes were implanted; 4 platinum electrodes; 8 contacts with 5 mm interelectrode spacing, with a total recording surface of 37 mm (Ad-Tech LTM—Spencer probe depth electrodes) and 3 platinum electrodes; and 10 contacts with 5 mm interelectrode spacing, with a total recording surface of 47mm (Ad-Tech LTM—Spencer probe depth electrodes). The Medtronic Stealth Station™ S8 was used to carry out the pre-operative planning using MR and CT angiography with sequences for neuronavigation . The electrodes were positioned under frameless Medtronic Stealth Autoguide™ cranial robotic guidance platform with the help of anchor bolts.\nElectrode course description is as follows: O (8 contacts) pars opercularis, S (10) superior parietal lobule, Ps (8) parietal, Pi (10) inferior parietal lobule, V (8) posterior portion of superior parietal gyrus, T (8) median temporal gyrus, and I (10) insula . From prolonged registration, frequent interictal anomalies were recorded on the deeper contacts of electrode O, I, and on Pi. Less frequent anomalies were found on the more lateral contacts of S and on the deeper ones of T and V. Five focal motor seizures were recorded showing onset on deep O, I, and Pi contacts with slight advance in the first 2 electrodes. Negative myoclonus was related to the presence of fast ripples on the deep contacts of O and I and subsequent slow potential on the most superficial contacts of I. Two electrical seizures were recorded on Ps. Finally, symptoms generally present during patient’s focal non-motor seizures were evoked with the stimulation of the contacts I3 and I4.", + "fulltext_subclaims": [ + "The patient is a 15-year-old boy.", + "The patient's clinical history started at 5 years old.", + "Seizures at onset were (1) imbalance and cold sensation.", + "Seizures at onset were (2) limbs and face paresthesia followed by loss of consciousness and limbs stiffening.", + "MRI scan showed a right parietal dysembryoplastic neuroepithelial tumor (DNET).", + "After surgical removal, the boy was seizure free for 2 years.", + "At 7 years old, focal seizures characterized by behavioral arrest, mental confusion, left upper limb paresthesia, and distorted voice sensations, followed by lower limb stiffening and weakness or imbalance appeared.", + "Long-term video EEG monitoring showed background rhythm asymmetry.", + "Long-term video EEG monitoring showed right centro-parieto-temporal interictal paroxysmal abnormalities.", + "Ictal EEG highlighted large slow right parietal and temporal waves preceded by rapid activity.", + "Seizures control lacked despite poly-antiepileptic drugs (AEDs) with valproate acid, oxcarbazepine, and clobazam.", + "Control MRI excluded tumor regrowth.", + "Control MRI showed only scar tissue on the superficial and deep-middle inferior parietal region extending to the marginal and angular gyrus, to the posterior insula, and to the inferior parietal gyrus behind rolandic cortex.", + "The child underwent a second surgery, aided by electrocorticography (ECoG).", + "The second surgery aimed to remove the altered sulci in the postero-medial portion of the previous surgical cavity.", + "The second surgery aimed to remove the right superior temporal gyrus.", + "Seizure freedom was achieved for 3 years.", + "Seizure relapsed after 2 years.", + "The boy experienced anesthesia and loss of tone in the left arm.", + "The boy experienced twisting of the jaw to the left and dysarthria.", + "The boy experienced daze, lightheadedness sometimes associated with headache and dizziness.", + "The boy experienced negative myoclonus involving the left hand.", + "A new pre-surgical epileptic work up was proposed.", + "The registration was made through 21 copper disc electrodes according to the International System 10-20.", + "The recording lasted 3 days.", + "The recording included Intermittent Light Stimulation protocol at increasing frequencies (3–50 Hz).", + "The recording included 5 minutes hyperventilation.", + "Data were analyzed using Micromed System View.", + "Interictal EEG was characterized by slow activity and spike and slow wave discharges on right central parietal regions.", + "Interictal EEG showed spike and slow wave discharges spreading on the posterior vertex ones.", + "Independent and isolated spikes on right posterior temporal derivations were also observed.", + "Three types of seizures were recorded.", + "Focal motor seizures were characterized by discharges of spike-wave on the right parietal regions with subsequent bihemispheric diffusion.", + "Focal non-motor seizures were characterized by delta-like slow activity.", + "Spike-wave on the right centro-parietal regions with right hemispheric diffusion and negative myoclonus were recorded.", + "Negative myoclonus was characterized by slow wave discharges on the right parietal and frontal regions with diffusion on the contra lateral homologous regions.", + "Cognitive assessment was carried out using the Wechsler Intelligence Scale for Children (version IV, 2003).", + "The Wechsler Intelligence Scale for Children highlighted a normal level (IQ 88).", + "The Wechsler Intelligence Scale for Children highlighted a disharmonic profile.", + "There was a significant difference (> 12 points) between the indices, to the detriment of the score obtained in working memory (73).", + "There was a significant difference (> 12 points) between the indices, to the detriment of the score obtained in processing speed (82).", + "Visuo-spatial memory was quite impaired (recall of Rey figure—5ds).", + "Verbal memory tests showed normal performance in short-term recall.", + "Verbal memory tests showed slight difficulty in long-term recall.", + "There was a marked difficulty in lexical retrieval with a phonological facilitator.", + "There was a slight difficulty in lexical retrieval with a semantic facilitator.", + "Tests performed with Developmental Neuropsychological Assessment (NEPSY-II, 2007) showed a marked deficit in sustained attention.", + "Tests performed with Developmental Neuropsychological Assessment (NEPSY-II, 2007) showed a slight difficulty in visual-motor integration.", + "A scalp hdEEG with 128 channels was performed.", + "The registration was made through pre-assembled caps with 128 electrodes according to the 10-10 system.", + "Electrode impedances were < 40 kΩ.", + "The sampling frequency was 1 kHz.", + "The vertex was used as recording reference.", + "The recording lasted about 2 h including wake and sleep.", + "No seizures were recorded.", + "Offline, EEG was analyzed through the Micromed SystemView.", + "Band pass filtering was between 0.1 and 100 Hz.", + "Any paroxysmal anomalies were noted.", + "A head model was built using T1-weighted MRI.", + "Scalp electrodes were co-registered with the MRI using a template net of electrodes with standard position.", + "The template net was translated/rotated/dilated with personalized digitalization through scalp navigation system (XensorTM 3D Electrode Digitizer).", + "For the inverse solution, low resolution electromagnetic tomography (LORETA) was used through ASA® Experiment Manager® Software.", + "Only the solution point with maximal source strength was taken into account.", + "An interictal source was identified in the mesial part of the right superior parietal lobule.", + "Another source, of lesser force, was found in the right frontal lobe at the level of the right prefrontal area.", + "SEEG was also performed.", + "Seven depth electrodes were implanted.", + "Four platinum electrodes were used.", + "Eight contacts with 5 mm interelectrode spacing were used.", + "A total recording surface of 37 mm was used.", + "Three platinum electrodes were used.", + "Ten contacts with 5 mm interelectrode spacing were used.", + "A total recording surface of 47 mm was used.", + "The Medtronic Stealth Station™ S8 was used to carry out the pre-operative planning.", + "MR and CT angiography with sequences for neuronavigation were used.", + "The electrodes were positioned under frameless Medtronic Stealth Autoguide™ cranial robotic guidance platform.", + "The help of anchor bolts was used.", + "Electrode course description is as follows: O (8 contacts) pars opercularis.", + "Electrode course description is as follows: S (10) superior parietal lobule.", + "Electrode course description is as follows: Ps (8) parietal.", + "Electrode course description is as follows: Pi (10) inferior parietal lobule.", + "Electrode course description is as follows: V (8) posterior portion of superior parietal gyrus.", + "Electrode course description is as follows: T (8) median temporal gyrus.", + "Electrode course description is as follows: I (10) insula.", + "Frequent interictal anomalies were recorded on the deeper contacts of electrode O.", + "Frequent interictal anomalies were recorded on the deeper contacts of electrode I.", + "Frequent interictal anomalies were recorded on the deeper contacts of electrode Pi.", + "Less frequent anomalies were found on the more lateral contacts of S.", + "Less frequent anomalies were found on the deeper ones of T.", + "Less frequent anomalies were found on the deeper ones of V.", + "Five focal motor seizures were recorded showing onset on deep O, I, and Pi contacts.", + "Negative myoclonus was related to the presence of fast ripples on the deep contacts of O and I.", + "Negative myoclonus was related to the presence of subsequent slow potential on the most superficial contacts of I.", + "Two electrical seizures were recorded on Ps.", + "Symptoms generally present during patient’s focal non-motor seizures were evoked with the stimulation of the contacts I3 and I4." + ], + "summary": "We report the case of a 15 years old boy suffering from drug resistant epilepsy with a previous history of DNET removal. The patient suffered from heterogeneous seizure semiology characterized by anesthesia and loss of tone in the left arm, twisting of the jaw to the left and dysarthria accompanied by daze; lightheadedness sometimes associated with headache and dizziness and at a relatively short time distance negative myoclonus involving the left hand. Clinical evidence poorly match scalp and video EEG monitoring thus requiring hdEEG recording followed by SEEG to define surgical target. Surgery was also guided by ECoG and obtained seizure freedom.", + "summary_subclaims": [ + "The patient is a 15 years old boy.", + "The patient suffers from drug resistant epilepsy.", + "The patient has a previous history of DNET removal.", + "The patient's seizure semiology is heterogeneous.", + "The seizure semiology includes anesthesia and loss of tone in the left arm.", + "The seizure semiology includes twisting of the jaw to the left.", + "The seizure semiology includes dysarthria accompanied by daze.", + "The seizure semiology includes lightheadedness sometimes associated with headache and dizziness.", + "The seizure semiology includes negative myoclonus involving the left hand.", + "Clinical evidence poorly matches scalp and video EEG monitoring.", + "hdEEG recording was performed.", + "SEEG was performed.", + "Surgery was guided by ECoG.", + "Surgery obtained seizure freedom." + ] + }, + { + "id": "multiclinsum_test_3090_en.txt", + "fulltext": "A 53-year-old man, who had been receiving pembrolizumab at a dosage of 2 mg/kg every 3 weeks for invasive bladder cancer, developed itchy, erythematous papules on his legs, without a febrile condition, following his 11th infusion. Histological examination of the bladder cancer revealed urothelial carcinoma with a G3 malignancy grade and detected a Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation. The skin lesions progressively spread to his entire trunk and extremities. Some of these lesions evolved into purpuric papules and, within a month of their onset, were accompanied by pustules and crusted ulcers. A 4-mm trepan punch biopsy taken from an erythematous papule on his leg revealed acanthosis, parakeratosis, several apoptosis keratinocytes, and spongiosis. Additionally, perivascular and band-like lymphocytic infiltration, predominantly with vacuolar alteration of the basal layer, was evident. Immunohistochemistry showed infiltration of both CD4+ and CD8+ T cells in the epidermis and papillary dermis, with a predominance of CD8+ cells. Granzyme B-positive inflammatory cells were also slightly present. A blood test indicated an elevated C-reactive protein level at 2.54 mg/dL. Based on the clinical and histopathological findings, particularly the characteristic necrosis, he was diagnosed with PLEVA. Despite the discontinuation of pembrolizumab and the initiation of topical corticosteroids, the purpuric papules increased. Approximately 2 weeks after starting oral prednisolone (10 mg/day), the skin rash and itching gradually improved. Due to concerns about a repause of cutaneous manifestations, pembrolizumab treatment was discontinued.", + "fulltext_subclaims": [ + "The patient is a 53-year-old man.", + "The patient had been receiving pembrolizumab at a dosage of 2 mg/kg every 3 weeks.", + "The pembrolizumab treatment was for invasive bladder cancer.", + "The patient developed itchy, erythematous papules on his legs.", + "The skin lesions developed following his 11th infusion.", + "The patient did not have a febrile condition.", + "Histological examination revealed urothelial carcinoma.", + "The bladder cancer was graded as G3.", + "A KRAS mutation was detected in the bladder cancer.", + "The skin lesions progressively spread to his entire trunk and extremities.", + "Some lesions evolved into purpuric papules.", + "Within a month of their onset, the lesions were accompanied by pustules and crusted ulcers.", + "A 4-mm trepan punch biopsy was taken from an erythematous papule on his leg.", + "The biopsy revealed acanthosis.", + "The biopsy revealed parakeratosis.", + "The biopsy revealed several apoptosis keratinocytes.", + "The biopsy revealed spongiosis.", + "Perivascular and band-like lymphocytic infiltration was evident.", + "The infiltration showed vacuolar alteration of the basal layer.", + "Immunohistochemistry showed infiltration of both CD4+ and CD8+ T cells in the epidermis and papillary dermis.", + "CD8+ cells were predominant in the infiltration.", + "Granzyme B-positive inflammatory cells were slightly present.", + "A blood test indicated an elevated C-reactive protein level at 2.54 mg/dL.", + "The patient was diagnosed with PLEVA.", + "Pembrolizumab treatment was discontinued.", + "Topical corticosteroids were initiated.", + "The purpuric papules increased despite the discontinuation of pembrolizumab and initiation of topical corticosteroids.", + "Oral prednisolone at 10 mg/day was started.", + "Approximately 2 weeks after starting oral prednisolone, the skin rash and itching gradually improved.", + "Due to concerns about a repause of cutaneous manifestations, pembrolizumab treatment was discontinued." + ], + "summary": "A 53-year-old man, receiving pembrolizumab for invasive bladder cancer, developed erythematous papules on his legs after his 11th infusion. The skin lesions gradually spread to his entire trunk and extremities. A punch biopsy revealed several apoptotic keratinocytes and spongiosis, along with perivascular and lichenoid lymphocytic infiltration with vacuolar alteration. Immunohistochemistry showed infiltration of CD4+ and CD8+ T cells in both the epidermis and dermis. Granzyme B-positive inflammatory cells were also slightly present. From these results, he was diagnosed with PLEVA, which might be classified as a lichenoid eruption, especially based on the histological findings.", + "summary_subclaims": [ + "The patient is a 53-year-old man.", + "The patient is receiving pembrolizumab for invasive bladder cancer.", + "The patient developed erythematous papules on his legs after his 11th infusion.", + "The skin lesions gradually spread to his entire trunk and extremities.", + "A punch biopsy revealed several apoptotic keratinocytes and spongiosis.", + "A punch biopsy revealed perivascular and lichenoid lymphocytic infiltration with vacuolar alteration.", + "Immunohistochemistry showed infiltration of CD4+ and CD8+ T cells in both the epidermis and dermis.", + "Granzyme B-positive inflammatory cells were also slightly present.", + "He was diagnosed with PLEVA.", + "PLEVA might be classified as a lichenoid eruption." + ] + }, + { + "id": "multiclinsum_test_3393_en.txt", + "fulltext": "A previously healthy 9-month-old local Chinese boy presented to emergency department with acute onset of generalised seizures. He was well except for mild upper respiratory tract symptoms with intermittent low-grade fever a week prior. There was no reported history of trauma. The seizures had started at his childcare centre after receiving a bath and milk feed. Emergency Medical Services (EMS) was activated and arrived approximately 20 min later. His childcare teacher, who had no prior basic life support training, commenced chest compressions and rescue breathing prior while waiting for EMS, as he appeared off-colour during the seizures. Paramedics on arrival assessed that he had a pulse and cardiac output; therefore he was given rescue breaths via bag-valve-mask ventilation en-route to the nearest emergency department.\n\nHe was brought to the nearest general hospital with no specialised paediatric services. His vital signs were: heart rate of 144 beats/minute, blood pressure of 130/72 mmHg, SpO2 was 83% on bag-valve-mask ventilation by paramedics, and axillary temperature was 36 degrees Celsius. As he continued to have more generalised tonic-clonic seizures, he was intubated with rapid-sequence-intubation and mechanically ventilated thereafter. He also received 10 ml/kg of normal saline fluid bolus for persistent tachycardia and poor peripheral perfusion. He was started on midazolam infusion and was transferred to our Children’s Emergency for further management.\n\nAt our Children’s Emergency, about 45 min after initial resuscitation, his vital signs were reflective of ongoing sympathetic overdrive. He was severely tachycardic (heart rate was 180 beats/minute) and markedly hypertensive despite repeated non-invasive blood pressure measurements from all limbs (blood pressure was 191/120 mmHg). He also had frequent desaturations to SpO2 80 to 90% (on FiO2 100% via bag-and-mask ventilation) with audible leak. He was poorly perfused but central pulses were present. Bilateral diffuse crackles were heard on lung auscultation, and there was large amount of frothy endotracheal tube (ETT) secretions that required frequent tube suctioning. Dual heart sounds were appreciated with no murmur. Liver edge was felt 1 cm below right subcostal margin, and no organomegaly was noted. Neurological examination revealed generalised hypotonia, areflexia, with no plantar response elicited, likely due to residual muscle relaxant effect. There were no external injuries found. Fundoscopy was not possible as his pupils were pinpoint due to ongoing midazolam infusion. Further history from his childcare teacher and both parents did not suggest an apparent unifying diagnosis for his clinical presentation then. Computed topography (CT) scan of the brain showed acute subdural haemorrhages along the posterior falx, left tentorial leaflet and overlying both high parietofrontal convexities. No significant mass effect, hydrocephalus, brain herniation or acute territorial infarct was noted. As he continued to have frequent recurrent desaturations despite ETT suctioning which by then yielded blood-stained frothy secretions, he was re-intubated with Size 4.5 cuff ETT (previous ETT was Size 4, uncuff), as these events were attributed initially to high leak and resultant inadequate ventilation. Prior to transfer to the paediatric intensive care unit (PICU), his blood pressure had returned to normal values, but his SpO2 continued to fluctuate between 80 to 90% on FiO2 100% despite high ventilatory pressures. Neuroprotective measures were instituted.\n\nOn transfer to the PICU, he continued to have persistent desaturation (SpO2 70–80%) despite adequate ventilation of the patient. Chest X-ray showed bilateral pulmonary airspace shadowing and infiltrates suggesting pulmonary oedema. Oxygenation index ranged from 22 to 37.8 in the next 6 h. The patient also continued to have brief clinical seizures and was treated with anti-epileptic medication. He also had worsening haemodynamics, necessitating commencement of inotropic support with adrenaline infusion of 0.03 to 0.1mcg/kg/min to maintain adequate blood pressure.\n\nBedside transthoracic 2D-echocardiogram subsequently showed moderate to severe reduction of LV systolic function and moderately reduced right ventricular systolic function. LV ejection fraction (biplane Simpson) was scored at 31% and fractional shortening was 25%. Hypokinesia involving predominantly the mid LV to LV apex was noted with a qualitatively dilated left atrium and mildly dilated LV. Normal origins of left and right coronary arteries were seen. There was no structural abnormality. Serum creatine kinase (CK) and creatine kinase-MB (CKMB) were normal at 87 U/L and 5.1 μg/L respectively, but troponin I was elevated at 392 ng/L. N-terminal proB-type natriuretic peptide (NT-ProBNP) was normal at 1223 pg/ml. 12-lead electrocardiogram showed sinus tachycardia with no ST elevation or T-wave inversion.\n\nWith the 2D-echocardiogram findings and abovementioned initial investigations, we narrowed the differentials to acquired causes: acute viral myocarditis versus Takotsubo cardiomyopathy triggered by a hyperacute stress response after an acute severe brain injury accompanied by status epilepticus.\n\nIntravenous furosemide was given to offload a dilated LV, and milrinone infusion was started at 0.5 to 0.7mcg/kg/min to reduce LV afterload. The patient continued to deteriorate with type 2 respiratory failure due to refractory pulmonary oedema secondary to LV systolic failure despite best medical management. Within 10 h of admission to the PICU, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated. ECMO flow ranged from 0.7 to 0.98 LPM (Cardiac index of 2.0 to 2.1 based on his basal surface area). He was peripherally cannulated via right internal jugular vein and right common carotid artery. The extracorporeal circuit was anticoagulated with systemic heparin. There was no haematological complication, even though he had coexisting bilateral subdural haemorrhages on admission. The pulmonary radiological changes on serial Chest X-rays improved remarkably within less than 24 h. Repeat 2D-echocardiogram done in less than 24 h from ECMO initiation also showed satisfactory biventricular free wall function with mildly dyskinetic interventricular septum, which was significantly improved when comparing with the admission scan. Investigations were performed to evaluate for possible infective myocarditis and encephalitis, and all of these yielded negative results (blood and urine cultures, and viral PCR studies). He was on ECMO for total of 57 h, and was subsequently successfully decannulated.\n\nThis was a dangerously ill 9-month-old boy who was previously well presenting with several clinical problems – firstly, convulsive status epilepticus as a result of acute severe brain injury for which CT imaging revealed bilateral acute subdural haemorrhages despite not having a known history of trauma; secondly, rapidly deteriorating cardiogenic shock with resultant flash pulmonary oedema resulting in respiratory failure despite being on high ventilatory support, finally requiring ECMO support. Possible differential diagnoses considered for his acute brain injury were that of underlying undiagnosed bleeding diathesis, intracranial vascular malformation, aneurysm or neoplasia, cerebral infections, rare metabolic disorders such as glutaric aciduria, and lastly non-accidental injury (NAI). His initial coagulation profile and full blood count were both normal, and had no previous or family history suggestive of an underlying bleeding diathesis. His clinical presentation, initial white blood cell count and inflammatory markers did not suggest bacterial sepsis or meningitis, and later viral studies did not suggest viral encephalitis. Magnetic resonance imaging (MRI) brain that was done 2 days after decannulation from ECMO showed bilateral subdural haematomas and mild sulcal subarachnoid haemorrhage. There was diffuse symmetrical white and grey matter signal abnormality and focal areas of parenchymal swelling. These features were suggestive of diffuse brain injury, which may have been a result of hypoxic-ischaemic injury, post-seizure changes, toxic and metabolic derangements or post-trauma changes. Magnetic resonance angiography (MRA) brain scan and transcranial doppler (TCD) of major cerebral vessels were both normal. Comprehensive metabolic workup did not reveal any underlying metabolic disorder. Slit-lamp examination of the eyes, which was done on the second day of admission, revealed extensive acute bilateral intra-retinal haemorrhages, raising the possibility of shaken baby syndrome. A full skeletal survey did not reveal any other bone fractures. A thorough investigation by the local justice system did not uncover any proof of NAI at home or at his childcare centre.", + "fulltext_subclaims": [ + "The patient was a previously healthy 9-month-old local Chinese boy.", + "He presented with acute onset of generalised seizures.", + "He had mild upper respiratory tract symptoms with intermittent low-grade fever a week prior.", + "There was no reported history of trauma.", + "The seizures started at his childcare centre after receiving a bath and milk feed.", + "Emergency Medical Services (EMS) was activated and arrived approximately 20 min later.", + "His childcare teacher, who had no prior basic life support training, commenced chest compressions and rescue breathing.", + "Paramedics on arrival assessed that he had a pulse and cardiac output.", + "He was given rescue breaths via bag-valve-mask ventilation en-route to the nearest emergency department.", + "He was brought to the nearest general hospital with no specialised paediatric services.", + "His heart rate was 144 beats/minute.", + "His blood pressure was 130/72 mmHg.", + "His SpO2 was 83% on bag-valve-mask ventilation by paramedics.", + "His axillary temperature was 36 degrees Celsius.", + "He continued to have more generalised tonic-clonic seizures.", + "He was intubated with rapid-sequence-intubation.", + "He received 10 ml/kg of normal saline fluid bolus.", + "He was started on midazolam infusion.", + "He was transferred to the Children’s Emergency.", + "At the Children’s Emergency, his heart rate was 180 beats/minute.", + "His blood pressure was 191/120 mmHg.", + "He had frequent desaturations to SpO2 80 to 90%.", + "He had bilateral diffuse crackles on lung auscultation.", + "There was a large amount of frothy endotracheal tube secretions.", + "Neurological examination revealed generalised hypotonia.", + "Neurological examination revealed areflexia.", + "No external injuries were found.", + "Computed topography (CT) scan of the brain showed acute subdural haemorrhages.", + "No significant mass effect, hydrocephalus, brain herniation or acute territorial infarct was noted.", + "He was re-intubated with Size 4.5 cuff ETT.", + "Prior to transfer to the PICU, his blood pressure had returned to normal values.", + "His SpO2 continued to fluctuate between 80 to 90%.", + "He was transferred to the PICU.", + "He continued to have persistent desaturation (SpO2 70–80%).", + "Chest X-ray showed bilateral pulmonary airspace shadowing.", + "Oxygenation index ranged from 22 to 37.8.", + "He had brief clinical seizures.", + "He was treated with anti-epileptic medication.", + "He had worsening haemodynamics.", + "Inotropic support with adrenaline infusion was commenced.", + "Bedside transthoracic 2D-echocardiogram showed moderate to severe reduction of LV systolic function.", + "LV ejection fraction was scored at 31%.", + "Fractional shortening was 25%.", + "Hypokinesia involving predominantly the mid LV to LV apex was noted.", + "Normal origins of left and right coronary arteries were seen.", + "There was no structural abnormality.", + "Troponin I was elevated at 392 ng/L.", + "NT-ProBNP was normal at 1223 pg/ml.", + "12-lead electrocardiogram showed sinus tachycardia.", + "Differentials were narrowed to acute viral myocarditis versus Takotsubo cardiomyopathy.", + "Intravenous furosemide was given.", + "Milrinone infusion was started.", + "The patient continued to deteriorate with type 2 respiratory failure.", + "Venovenous extracorporeal membrane oxygenation (VA-ECMO) support was initiated.", + "ECMO flow ranged from 0.7 to 0.98 LPM.", + "He was peripherally cannulated via right internal jugular vein and right common carotid artery.", + "The extracorporeal circuit was anticoagulated with systemic heparin.", + "There was no haematological complication.", + "The pulmonary radiological changes improved remarkably within less than 24 h.", + "Repeat 2D-echocardiogram showed satisfactory biventricular free wall function.", + "Infections were ruled out with negative blood and urine cultures.", + "He was on ECMO for a total of 57 h.", + "He was successfully decannulated.", + "MRI brain showed bilateral subdural haematomas.", + "MRI brain showed mild sulcal subarachnoid haemorrhage.", + "MRI brain showed diffuse symmetrical white and grey matter signal abnormality.", + "MRI brain showed focal areas of parenchymal swelling.", + "MRA brain scan and TCD of major cerebral vessels were both normal.", + "Comprehensive metabolic workup did not reveal any underlying metabolic disorder.", + "Slit-lamp examination revealed extensive acute bilateral intra-retinal haemorrhages.", + "A full skeletal survey did not reveal any other bone fractures.", + "A thorough investigation by the local justice system did not uncover any proof of NAI." + ], + "summary": "A previously healthy 9-month-old local Chinese boy presented with generalised seizures secondary to acute severe brain injury, with signs of sympathetic overdrive, followed by rapidly progressive cardiogenic shock and respiratory failure, eventually requiring ECMO support. Neuroimaging at presentation revealed bilateral subdural haemorrhages. His cardiac function recovered within the next 24 h revealing the reversibility nature of Takotsubo cardiomyopathy.", + "summary_subclaims": [ + "The patient is a 9-month-old local Chinese boy.", + "The patient had generalised seizures.", + "The seizures were secondary to acute severe brain injury.", + "The patient had signs of sympathetic overdrive.", + "The patient had rapidly progressive cardiogenic shock.", + "The patient had respiratory failure.", + "The patient required ECMO support.", + "Neuroimaging at presentation revealed bilateral subdural haemorrhages.", + "Cardiac function recovered within the next 24 h.", + "The recovery revealed the reversibility nature of Takotsubo cardiomyopathy." + ] + }, + { + "id": "multiclinsum_test_2077_en.txt", + "fulltext": "A seventy-eight year-old man, without previous skin lesions or skin scars\nconsistent with tegumentary leishmaniasis (TL), evolved during the last\nyear with volume increase in the nasal pyramid to the right side, nasal obstruction,\nepistaxis to manipulation of nasal cavities, crusting and occasional cacosmia. He\nalso had 117 mg/dL glucose; 48 mg/dL urea; 1.5 mg/dL creatinine; 78\nmg/dL amylase; 22 U/L AST; 30 U/L ALT; 74 U/L ALP. Systemic\narterial hypertension was treated with 25 mg/day hydrochlorothiazide 20\nmg/day nifedipine, 2 mg/day doxazosin mesylate, besides 50 mg SOS sodium\ndiclofenac, due to chronic muscle pain. He reported bilateral hearing loss for the\nlast seven years, but he denied tinnitus, dizziness, noise exposure or family\nhistory of auditory and/or vestibular symptoms. Otoscopy was normal and the\nendoscopic examination of the upper aero-digestive tract presented infiltration of\nthe right nasal wing and the entire mucosa of the right nasal cavity, preventing\nprogression of optics. There was also infiltration of the vestibular region,\nanterior nasal septum and head of the left inferior turbinate, with discrete crusts,\nas well as absence of mucosal lesions in the pharynx and larynx. Syphilis and fungal\nserologies were negative. TL serologies performed were: 1:40 indirect\nimmunofluorescence technique and ELISA reactor. A nasal biopsy was performed.\nFragment cultures were negative to Leishmania, mycobacteria and\nfungus. The histopathological examination revealed chronic granulomatous\ninflammation with necrosis. The immunohistochemistry with\nanti-Leishmania serum showed occasional amastigote forms and\npolymerase chain reaction was positive to Leishmania. A\npre-treatment audiometric study showed mild to severe sensorineural hearing loss,\ntritone mean at 500-1000-2000 Hz of 53dB and 62dB, in the right and left ears,\nrespectively. Additionally, he presented bilateral type A tympanogram and\nbilaterally absent distortion product otoacoustic emissions (DPOAE).\nTreatment with meglumine antimoniate (MA) (Glucantime® from\nSanofi Aventis) was initiated at a maximum daily dose of three ampoules\n(weight 72 kg; dose 16.9 mgSb+5/kg/day) for 30\ndays.\nOn the twelfth day of treatment, the patient returned with herpes zoster\nin the buttock (dermatome S1) and myalgia, and acyclovir cream, urea cream\nand 50 mg of sodium diclofenac if pain were prescribed. He was asymptomatic from the\ncochlea-vestibular point of view, but presented a 10 dB increase of the auditory\nthreshold at 6 kHz and a 15 dB increase at 8 kHz in the left ear (LE). On\nthe twenty-sixth day, treatment was discontinued due to cutaneous rash, scaling of\nlower limbs, difficulty in walking, arthralgia, myalgia, hand tremor, dry oral\nmucosa, anorexia and loss of weight (-3 kg). He also presented frequent\nsevere rotatory dizziness lasting some minutes with no associated vagal symptoms,\nwithout worsening of hearing complaints previously reported. VENG was normal and the\naudiometry showed a 20 dB increase at 6 KHz and a 25 dB increase at 8 KHz in the LE.\nHe also had 153 mg/dL glucose; 83 mg/dL urea; 322 mg/dL amylase; 181\nU/L AST; 174 U/L ALT; 112 U/L ALP; 175 U/L GGT) and QTc\n0.46. Sixteen days after the treatment was discontinued, he maintained rare\nnon-rotatory dizziness lasting seconds, without objective worsening of hearing\ncomplaints, but with tinnitus, and he had fallen two days before. Pure tone\naudiometry presented severe worsening of LE auditory thresholds (10 dB increase\nat 250 Hz; 10 dB increase at 500 Hz; 15 dB increase at 1 KHz; 25 dB increase at 2\nKHz; 30 dB increase at 3 KHz; 15 dB increase at 6 KHz; and 45 dB increase at 8\nKHz) and VENG was within the normal range, although with reduction of more than\n50% of the previous value of Angular Velocity of the Slow Component of\nNystagmus in degrees per second (AVSC°/s) at 18 °C. He had\n118 mg/dL glucose; 30 mg/dL urea; 90 mg/dL amylase; 41 U/L AST;\n71 U/L ALT; 155 U/L ALP; 128 U/L GGT) and QTc 0.33. Twenty-eight\ndays after treatment interruption, he no longer had tinnitus and dizziness remained\nof mild intensity and lasting seconds. He walked adequately and myalgia and tremors\nhad improved. Pure audiometry showed no more increments consistent with ototoxicity\ncriterion. He had 110 mg/dL glucose; 1.4 mg/dL creatinine; 105 mg/dL\namylase; 371 mg/dL lypase; 34 U/L AST; 43 U/L ALT; 115 U/L ALP;\n80 U/L GGT) and QTc 0.33. As the patient still presented mucosa lesions 90\ndays after treatment interruption, he was successfully treated with 150 mg/day\n(2.2 mg/kg/day) liposomal amphotericin B, up to an accumulated\ndose of 1800 mg, when it was discontinued due to serum creatinine value of 1.6\nmg/dL, without worsening of hearing and/or dizziness complaints. A year\nand four months later, he did not present worsening of hearing complaints when\ncompared to the beginning of treatment with MA, neither tinnitus nor dizziness, and\nthe audiometry was not consistent with ototoxicity criterion and VENG was within the\nnormal range, with AVSC in the LE at 18 °C returning to values similar to the\nbeginning of symptomatology. The DPOAE examination remained absent during the entire\nmonitoring. (Pure tone audiometry through air conduction of the left ear of\na patient during the monitoring process, IPEC, FioCruz, Rio de Janeiro, 2011)\nand 2 (Variations of Angular Velocity of the Slow Component of Nystagmus in\ndegrees per second (AVSC °/s) of the patient during the\nmonitoring process - IPEC, FioCruz, Rio de Janeiro, 2011) show the variations\nin pure tone audiometry and of the angular velocity of the slow component of\nnystagmus, during the patient's follow-up.", + "fulltext_subclaims": [ + "The patient is a 78-year-old man.", + "The patient had no previous skin lesions or skin scars consistent with tegumentary leishmaniasis.", + "The patient had a volume increase in the nasal pyramid to the right side.", + "The patient had nasal obstruction.", + "The patient had epistaxis to manipulation of nasal cavities.", + "The patient had crusting.", + "The patient had occasional cacosmia.", + "The patient had 117 mg/dL glucose.", + "The patient had 48 mg/dL urea.", + "The patient had 1.5 mg/dL creatinine.", + "The patient had 78 mg/dL amylase.", + "The patient had 22 U/L AST.", + "The patient had 30 U/L ALT.", + "The patient had 74 U/L ALP.", + "The patient had systemic arterial hypertension.", + "The patient was treated with 25 mg/day hydrochlorothiazide.", + "The patient was treated with 20 mg/day nifedipine.", + "The patient was treated with 2 mg/day doxazosin mesylate.", + "The patient was treated with 50 mg SOS sodium diclofenac.", + "The patient reported bilateral hearing loss for the last seven years.", + "The patient denied tinnitus.", + "The patient denied dizziness.", + "The patient denied noise exposure.", + "The patient denied family history of auditory and/or vestibular symptoms.", + "Otoscopy was normal.", + "The endoscopic examination of the upper aero-digestive tract presented infiltration of the right nasal wing.", + "The endoscopic examination of the upper aero-digestive tract presented infiltration of the entire mucosa of the right nasal cavity.", + "The endoscopic examination of the upper aero-digestive tract prevented progression of optics.", + "The endoscopic examination of the upper aero-digestive tract presented infiltration of the vestibular region.", + "The endoscopic examination of the upper aero-digestive tract presented infiltration of the anterior nasal septum.", + "The endoscopic examination of the upper aero-digestive tract presented infiltration of the head of the left inferior turbinate.", + "The endoscopic examination of the upper aero-digestive tract showed discrete crusts.", + "The endoscopic examination of the upper aero-digestive tract showed absence of mucosal lesions in the pharynx.", + "The endoscopic examination of the upper aero-digestive tract showed absence of mucosal lesions in the larynx.", + "Syphilis serology was negative.", + "Fungal serology was negative.", + "TL serologies performed were 1:40 indirect immunofluorescence technique.", + "TL serologies performed were ELISA reactor.", + "A nasal biopsy was performed.", + "Fragment cultures were negative to Leishmania.", + "Fragment cultures were negative to mycobacteria.", + "Fragment cultures were negative to fungus.", + "The histopathological examination revealed chronic granulomatous inflammation with necrosis.", + "The immunohistochemistry with anti-Leishmania serum showed occasional amastigote forms.", + "The polymerase chain reaction was positive to Leishmania.", + "A pre-treatment audiometric study showed mild to severe sensorineural hearing loss.", + "The pre-treatment audiometric study showed a tritone mean at 500-1000-2000 Hz of 53 dB in the right ear.", + "The pre-treatment audiometric study showed a tritone mean at 500-1000-2000 Hz of 62 dB in the left ear.", + "The patient had bilateral type A tympanogram.", + "The patient had bilaterally absent distortion product otoacoustic emissions.", + "Treatment with meglumine antimoniate was initiated.", + "The treatment with meglumine antimoniate was at a maximum daily dose of three ampoules.", + "The treatment with meglumine antimoniate was for 30 days.", + "On the twelfth day of treatment, the patient returned with herpes zoster in the buttock.", + "On the twelfth day of treatment, the patient had myalgia.", + "On the twelfth day of treatment, acyclovir cream was prescribed.", + "On the twelfth day of treatment, urea cream was prescribed.", + "On the twelfth day of treatment, 50 mg of sodium diclofenac was prescribed if pain.", + "On the twelfth day of treatment, the patient was asymptomatic from the cochlea-vestibular point of view.", + "On the twelfth day of treatment, the patient had a 10 dB increase of the auditory threshold at 6 kHz in the left ear.", + "On the twelfth day of treatment, the patient had a 15 dB increase at 8 kHz in the left ear.", + "On the twenty-sixth day, treatment was discontinued due to cutaneous rash.", + "On the twenty-sixth day, treatment was discontinued due to scaling of lower limbs.", + "On the twenty-sixth day, treatment was discontinued due to difficulty in walking.", + "On the twenty-sixth day, treatment was discontinued due to arthralgia.", + "On the twenty-sixth day, treatment was discontinued due to myalgia.", + "On the twenty-sixth day, treatment was discontinued due to hand tremor.", + "On the twenty-sixth day, treatment was discontinued due to dry oral mucosa.", + "On the twenty-sixth day, treatment was discontinued due to anorexia.", + "On the twenty-sixth day, treatment was discontinued due to loss of weight (-3 kg).", + "On the twenty-sixth day, the patient had frequent severe rotatory dizziness lasting some minutes.", + "On the twenty-sixth day, the patient had no associated vagal symptoms.", + "On the twenty-sixth day, the patient had no worsening of hearing complaints previously reported.", + "On the twenty-sixth day, VENG was normal.", + "On the twenty-sixth day, audiometry showed a 20 dB increase at 6 kHz in the left ear.", + "On the twenty-sixth day, audiometry showed a 25 dB increase at 8 kHz in the left ear.", + "On the twenty-sixth day, the patient had 153 mg/dL glucose.", + "On the twenty-sixth day, the patient had 83 mg/dL urea.", + "On the twenty-sixth day, the patient had 322 mg/dL amylase.", + "On the twenty-sixth day, the patient had 181 U/L AST.", + "On the twenty-sixth day, the patient had 174 U/L ALT.", + "On the twenty-sixth day, the patient had 112 U/L ALP.", + "On the twenty-sixth day, the patient had 175 U/L GGT.", + "On the twenty-sixth day, the patient had QTc 0.46.", + "Sixteen days after treatment was discontinued, the patient had rare non-rotatory dizziness lasting seconds.", + "Sixteen days after treatment was discontinued, the patient had no objective worsening of hearing complaints.", + "Sixteen days after treatment was discontinued, the patient had tinnitus.", + "Sixteen days after treatment was discontinued, the patient had fallen two days before.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 10 dB increase at 250 Hz in the left ear.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 10 dB increase at 500 Hz in the left ear.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 15 dB increase at 1 kHz in the left ear.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 25 dB increase at 2 kHz in the left ear.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 30 dB increase at 3 kHz in the left ear.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 15 dB increase at 6 kHz in the left ear.", + "Sixteen days after treatment was discontinued, pure tone audiometry showed a 45 dB increase at 8 kHz in the left ear.", + "Sixteen days after treatment was discontinued, VENG was within the normal range.", + "Sixteen days after treatment was discontinued, VENG showed reduction of more than 50% of the previous value of Angular Velocity of the Slow Component of Nystagmus in degrees per second at 18 °C.", + "Sixteen days after treatment was discontinued, the patient had 118 mg/dL glucose.", + "Sixteen days after treatment was discontinued, the patient had 30 mg/dL urea.", + "Sixteen days after treatment was discontinued, the patient had 90 mg/dL amylase.", + "Sixteen days after treatment was discontinued, the patient had 41 U/L AST.", + "Sixteen days after treatment was discontinued, the patient had 71 U/L ALT.", + "Sixteen days after treatment was discontinued, the patient had 155 U/L ALP.", + "Sixteen days after treatment was discontinued, the patient had 128 U/L GGT.", + "Sixteen days after treatment was discontinued, the patient had QTc 0.33.", + "Twenty-eight days after treatment interruption, the patient no longer had tinnitus.", + "Twenty-eight days after treatment interruption, the patient had dizziness of mild intensity and lasting seconds.", + "Twenty-eight days after treatment interruption, the patient walked adequately.", + "Twenty-eight days after treatment interruption, myalgia and tremors had improved.", + "Twenty-eight days after treatment interruption, pure audiometry showed no more increments consistent with ototoxicity criterion.", + "Twenty-eight days after treatment interruption, the patient had 110 mg/dL glucose.", + "Twenty-eight days after treatment interruption, the patient had 1.4 mg/dL creatinine.", + "Twenty-eight days after treatment interruption, the patient had 105 mg/dL amylase.", + "Twenty-eight days after treatment interruption, the patient had 371 mg/dL lypase.", + "Twenty-eight days after treatment interruption, the patient had 34 U/L AST.", + "Twenty-eight days after treatment interruption, the patient had 43 U/L ALT.", + "Twenty-eight days after treatment interruption, the patient had 115 U/L ALP.", + "Twenty-eight days after treatment interruption, the patient had 80 U/L GGT.", + "Twenty-eight days after treatment interruption, the patient had QTc 0.33.", + "As the patient still presented mucosa lesions 90 days after treatment interruption, he was successfully treated with 150 mg/day liposomal amphotericin B.", + "The treatment with liposomal amphotericin B was at 2.2 mg/kg/day.", + "The treatment with liposomal amphotericin B was up to an accumulated dose of 1800 mg.", + "The treatment with liposomal amphotericin B was discontinued due to serum creatinine value of 1.6 mg/dL.", + "The treatment with liposomal amphotericin B was discontinued without worsening of hearing and/or dizziness complaints.", + "A year and four months later, the patient did not present worsening of hearing complaints when compared to the beginning of treatment with meglumine antimoniate.", + "A year and four months later, the patient did not have tinnitus.", + "A year and four months later, the patient did not have dizziness.", + "A year and four months later, the audiometry was not consistent with ototoxicity criterion.", + "A year and four months later, VENG was within the normal range.", + "A year and four months later, the Angular Velocity of the Slow Component of Nystagmus in degrees per second at 18 °C returned to values similar to the beginning of symptomatology.", + "The DPOAE examination remained absent during the entire monitoring.", + "Figure 1 shows the variations in pure tone audiometry during the patient's follow-up.", + "Figure 2 shows the variations in the angular velocity of the slow component of nystagmus during the patient's follow-up." + ], + "summary": "A case of a tegumentary leishmaniasis patient, a 78-year-old man who presented a substantial increase in auditory threshold with tinnitus and severe rotatory dizziness during the treatment with meglumine antimoniate, is reported. These symptoms worsened in two weeks after treatment was interrupted.", + "summary_subclaims": [ + "A case of a tegumentary leishmaniasis patient is reported.", + "The patient is a 78-year-old man.", + "The patient presented a substantial increase in auditory threshold.", + "The patient had tinnitus.", + "The patient had severe rotatory dizziness.", + "The symptoms occurred during treatment with meglumine antimoniate.", + "The symptoms worsened in two weeks after treatment was interrupted." + ] + }, + { + "id": "multiclinsum_test_2884_en.txt", + "fulltext": "A 26-year-old woman had bilateral sensorineural deafness since birth and tonic-clonic seizure 1 month after birth. Her laboratory examination showed severe hypocalcemia and hyperphosphatemia, and serum iPTH levels were undetectable. She was diagnosed with congenital hypoparathyroidism, following which oral vitamin D supplementation was initiated. In, 20XX-5, calcification in bilateral kidneys was detected on abdominal ultrasonography, indicating renal dysfunction (serum creatinine level, 0.8–1.1 mg/dL).\nSubsequently, she consulted our institute in October 20XX; the laboratory examination revealed her urine calcium/creatinine (Ca/Cr) ratio was 0.25 and serum iPTH level was 0.2 pg/mL. Abdominal CT revealed severe nephrocalcinosis . Arterial blood gas analysis was unremarkable and tubular acidosis was not indicated. The urine calcium level was adjusted; her urine Ca/Cr ratio was controlled between 0.2 and 0.3. However, her renal calcification persisted. Thereafter, her renal dysfunction rapidly progressed and she was started on dialysis in February 2013, and LDKT was simultaneously planned. In June 20XX + 1, GATA3 mutation was confirmed by genetic analysis, and she was diagnosed with HDR syndrome.\nIn January 20XX + 7, ABO-incompatible LDKT was performed. The donor was her mother, who did not have GATA3 mutation. She received double filtration plasmapheresis, plasma exchange, and immunosuppressive regimen, including cyclosporine, mycophenolate mofetil, prednisone, and basiliximab. Rituximab was also administered twice on the day and two weeks before LDKT.\nAfter LDKT, her serum creatinine level continued to decrease . Her serum and urine calcium level was maintained at a normal range (urine Ca/Cr ratio ≤0.1). Her graft function was fine (serum creatinine 0.9–1.0 mg/dL), and graft calcification was not observed 1 year after LDKT .", + "fulltext_subclaims": [ + "The patient is a 26-year-old woman.", + "She had bilateral sensorineural deafness since birth.", + "She had a tonic-clonic seizure 1 month after birth.", + "Her laboratory examination showed severe hypocalcemia.", + "Her laboratory examination showed hyperphosphatemia.", + "Her serum iPTH levels were undetectable.", + "She was diagnosed with congenital hypoparathyroidism.", + "Oral vitamin D supplementation was initiated.", + "In 20XX-5, calcification in bilateral kidneys was detected on abdominal ultrasonography.", + "The calcification indicated renal dysfunction.", + "Her serum creatinine level was 0.8–1.1 mg/dL.", + "She consulted our institute in October 20XX.", + "Her urine calcium/creatinine (Ca/Cr) ratio was 0.25.", + "Her serum iPTH level was 0.2 pg/mL.", + "Abdominal CT revealed severe nephrocalcinosis.", + "Arterial blood gas analysis was unremarkable.", + "Tubular acidosis was not indicated.", + "Her urine Ca/Cr ratio was controlled between 0.2 and 0.3.", + "Her renal calcification persisted.", + "Her renal dysfunction rapidly progressed.", + "She was started on dialysis in February 2013.", + "LDKT was simultaneously planned.", + "In June 20XX + 1, GATA3 mutation was confirmed by genetic analysis.", + "She was diagnosed with HDR syndrome.", + "In January 20XX + 7, ABO-incompatible LDKT was performed.", + "The donor was her mother.", + "The donor did not have GATA3 mutation.", + "She received double filtration plasmapheresis.", + "She received plasma exchange.", + "She received an immunosuppressive regimen including cyclosporine, mycophenolate mofetil, prednisone, and basiliximab.", + "Rituximab was administered twice on the day and two weeks before LDKT.", + "After LDKT, her serum creatinine level continued to decrease.", + "Her serum and urine calcium level was maintained at a normal range.", + "Her urine Ca/Cr ratio was ≤0.1.", + "Her graft function was fine.", + "Her serum creatinine was 0.9–1.0 mg/dL.", + "Graft calcification was not observed 1 year after LDKT." + ], + "summary": "This case pertains to a 26-year-old woman who was diagnosed with congenital hypoparathyroidism 1 month after birth, following which vitamin D supplementation was initiated. In 20XX, she developed nephrocalcinosis and was confirmed to have a GATA3 mutation; hence, she was diagnosed with hypoparathyroidism, sensorineural deafness, and renal dysplasia syndrome. In 20XX + 7, ABO-incompatible living-donor kidney transplantation was performed. Her renal function improved, and graft calcification was not observed.", + "summary_subclaims": [ + "The patient is a 26-year-old woman.", + "She was diagnosed with congenital hypoparathyroidism 1 month after birth.", + "Vitamin D supplementation was initiated.", + "In 20XX, she developed nephrocalcinosis.", + "She was confirmed to have a GATA3 mutation.", + "She was diagnosed with hypoparathyroidism, sensorineural deafness, and renal dysplasia syndrome.", + "In 20XX + 7, ABO-incompatible living-donor kidney transplantation was performed.", + "Her renal function improved.", + "Graft calcification was not observed." + ] + }, + { + "id": "multiclinsum_test_3215_en.txt", + "fulltext": "A 13-year-old girl with intellectual disability experienced epilepsy and fatigue for two years, with a recent event of edema, breathlessness, and nocturnal dyspnea that prompted admission to the Cardiology Department of Beijing Children’s Hospital. She had a fever and convulsions 2 years before admission and was treated with oral digoxin, prednisone acetate, and captopril at another hospital. Her prenatal and perinatal history was unremarkable. Her family had no similar health issues.\n\nTwo weeks before admission, the girl developed a cough, worsening dyspnea, breathlessness, and orthopnea. Antibiotics failed to improve her condition. Physical examination exhibited systolic murmur, jugular vein distention, and enlarged liver and spleen. Blood biochemistry showed elevated blood urea nitrogen (BUN) (12.95 mmol·L− 1), creatinine (1.1 mg·dl− 1), uric acid (734.1 µmol·L− 1), aspartate aminotransferase (63.8 U·L− 1), and alanine aminotransferase (97.6 U·L− 1) and low estimated creatinine clearance rate (53.98 ml/min/1.73 m2; bedside Schwart estimation). Troponin-I (0.132 ng·mL− 1) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (15,906 pg·mL− 1) levels were significantly increased. Blood pressure was 100–122/65–84 mmHg. The urine routine showed no abnormalities, including white cells, red cells, or proteinuria. The 24-hour urine volume was 820–1100 ml. Tests for urine organic acids and plasma amino acids were negative. Echocardiography showed a low ejection fraction (34%) and fractional shortening (16%). Echocardiography indicated heart enlargement and ventricular hypertrophy, suggesting cardiomyopathy. Edema, dyspnea, elevated NT-proBNP levels, and reduced ejection fraction were all indicative of heart failure. In addition, echocardiography revealed left cardiac dysfunction, general heart enlargement, ventricular hypertrophy, massive pericardial effusion, moderate regurgitation in multiple valves, and a severely reduced ejection fraction of 35%, further supporting the diagnosis of heart failure. Electrocardiography indicated paroxysmal ventricular tachycardia and ST-T wave alterations. Routine urine tests and a kidney ultrasound were conducted, revealing no evidence of proteinuria, hematuria, or morphological changes typical of NPHP, such as corticomedullary cysts or significant structural abnormalities. No kidney biopsy was performed, limiting a conclusive diagnosis of a kidney pathology based on histological assessment. Although the blood tests indicated elevated BUN and creatinine, these findings were considered to be acute kidney injury due to severe cardiac failure, which might lead to impaired kidney perfusion rather than primary kidney disease. After informed consent, genetic testing was conducted on the patient and her relatives. After filtering the non-candidate variants of the proband from the databases, a homozygous splicing mutation, XPNPEP3 c.970–2 A > G, was detected in intron 6, and no other related significant mutations were identified, establishing a diagnosis of NPHPL1. Using Sanger sequencing, this mutation was confirmed in the proband’s asymptomatic brother (heterozygous) and parents (recessive carriers). ESEfinder v.3.0 (http://rulai.cshl.edu/tools/ESE) predicted that c.970–2 A > G may reduce the binding of the splicing factors SRSF2 and SRSF5 to their target sequence, suggesting that the mutation may lead to abnormal splicing of XPNPEP3. Similar results were predicted by Human Splicing Finder (HSF) and the NetGene2 servers. Moreover, the experimental results of the minigene approach confirmed the deleterious effect of c.970–2 A > G. Agarose gel electrophoresis analysis of the PCR fragments revealed that the wild-type transcript had a longer band of 412 bp. In contrast, the mutant exhibited only one band of 326 bp, with the 86 bp band being absent. Sanger sequencing confirmed that the mutant plasmid transcribed a mature mRNA product with exon 7 being skipped entirely (86 bp del, c.970_1055del, NM_022098) in the mature mRNA, suggesting that c.970–2 A > G leads to the abnormal splicing of XPNPEP3 in the absence of nonsense-mediated mRNA decay.\n\nUpon admission, the patient received digoxin, milrinone, furosemide, hydrochlorothiazide, and spironolactone to enhance heart function and metoprolol to manage arrhythmias. Despite these interventions, she developed worsening edema, kidney failure, hypotension, and sustained ventricular tachycardia within 5 days. Her parents opted to transfer her to another facility for continued care. Tragically, the child passed away approximately 1 week after discharge. It is believed that the cause of death may originate from arrhythmias, as the child had ventricular tachycardia, which could lead to malignant arrhythmias and result in sudden cardiac death. Furthermore, the exacerbation of heart failure, likely due to complications from end-organ damage, may also have contributed to the outcome.", + "fulltext_subclaims": [ + "The patient was a 13-year-old girl with intellectual disability.", + "She had a 2-year history of epilepsy and fatigue.", + "She had a recent event of edema, breathlessness, and nocturnal dyspnea.", + "She was admitted to the Cardiology Department of Beijing Children’s Hospital.", + "She had a fever and convulsions 2 years before admission.", + "She was treated with oral digoxin, prednisone acetate, and captopril at another hospital.", + "Her prenatal and perinatal history was unremarkable.", + "Her family had no similar health issues.", + "Two weeks before admission, she developed a cough, worsening dyspnea, breathlessness, and orthopnea.", + "Antibiotics failed to improve her condition.", + "Physical examination exhibited systolic murmur.", + "Blood biochemistry showed elevated blood urea nitrogen (BUN) (12.95 mmol·L− 1).", + "Blood biochemistry showed elevated creatinine (1.1 mg·dl− 1).", + "Blood biochemistry showed elevated uric acid (734.1 µmol·L− 1).", + "Blood biochemistry showed elevated aspartate aminotransferase (63.8 U·L− 1).", + "Blood biochemistry showed elevated alanine aminotransferase (97.6 U·L− 1).", + "The estimated creatinine clearance rate was 53.98 ml/min/1.73 m2.", + "Troponin-I was 0.132 ng·mL− 1.", + "NT-proBNP was 15,906 pg·mL− 1.", + "Echocardiography showed a low ejection fraction (34%).", + "Echocardiography indicated heart enlargement and ventricular hypertrophy.", + "Echocardiography suggested cardiomyopathy.", + "Edema, dyspnea, elevated NT-proBNP levels, and reduced ejection fraction were indicative of heart failure.", + "Echocardiography revealed left cardiac dysfunction.", + "Echocardiography revealed general heart enlargement.", + "Echocardiography revealed ventricular hypertrophy.", + "Echocardiography revealed massive pericardial effusion.", + "Echocardiography revealed moderate regurgitation in multiple valves.", + "Echocardiography showed a severely reduced ejection fraction of 35%.", + "Electrocardiography indicated paroxysmal ventricular tachycardia.", + "Electrocardiography indicated ST-T wave alterations.", + "Routine urine tests showed no abnormalities.", + "Echocardiography further supported the diagnosis of heart failure.", + "No kidney biopsy was performed.", + "Elevated BUN and creatinine were considered to be acute kidney injury due to severe cardiac failure.", + "Genetic testing was conducted on the patient and her relatives.", + "A homozygous splicing mutation, XPNPEP3 c.970–2 A > G, was detected in intron 6.", + "No other related significant mutations were identified.", + "The mutation was confirmed in the proband’s asymptomatic brother (heterozygous).", + "The mutation was confirmed in the parents (recessive carriers).", + "ESEfinder v.3.0 predicted that c.970–2 A > G may reduce the binding of the splicing factors SRSF2 and SRSF5.", + "Human Splicing Finder and NetGene2 servers predicted similar results.", + "The minigene approach confirmed the deleterious effect of c.970–2 A > G.", + "Agarose gel electrophoresis analysis showed that the wild-type transcript had a longer band of 412 bp.", + "The mutant exhibited only one band of 326 bp.", + "The 86 bp band was absent in the mutant.", + "Sanger sequencing confirmed that the mutant plasmid transcribed a mature mRNA product with exon 7 being skipped entirely.", + "The mutation leads to the abnormal splicing of XPNPEP3.", + "The patient received digoxin, milrinone, furosemide, hydrochlorothiazide, and spironolactone.", + "She received metoprolol to manage arrhythmias.", + "She developed worsening edema, kidney failure, hypotension, and sustained ventricular tachycardia within 5 days.", + "Her parents opted to transfer her to another facility.", + "The child passed away approximately 1 week after discharge.", + "The cause of death may originate from arrhythmias.", + "The child had ventricular tachycardia, which could lead to malignant arrhythmias.", + "The exacerbation of heart failure may have contributed to the outcome." + ], + "summary": "A 13-year-old Chinese female patient with intellectual disability presented with a 2-year history of convulsions and fatigue, with a recent episode of swelling, breathlessness, and nocturnal dyspnea lasting 10 days. The patient was diagnosed with heart failure and kidney failure. Whole exome sequencing revealed a homozygous c.970–2 A > G mutation in XPNPEP3 associated with severe cardiac dysfunction and neurological symptoms, including epilepsy and intellectual disability. Notably, kidney ultrasound did not reveal the typical changes of NPHPL1, and kidney failure was hypothesized to be secondary to cardiac dysfunction rather than primary kidney pathology.", + "summary_subclaims": [ + "The patient is a 13-year-old Chinese female.", + "The patient has intellectual disability.", + "The patient had a 2-year history of convulsions.", + "The patient had a recent episode of swelling, breathlessness, and nocturnal dyspnea lasting 10 days.", + "The patient was diagnosed with heart failure.", + "The patient was diagnosed with kidney failure.", + "Whole exome sequencing revealed a homozygous c.970–2 A > G mutation in XPNPEP3.", + "The mutation is associated with severe cardiac dysfunction.", + "The mutation is associated with neurological symptoms, including epilepsy.", + "The mutation is associated with intellectual disability.", + "Kidney ultrasound did not reveal the typical changes of NPHPL1.", + "Kidney failure was hypothesized to be secondary to cardiac dysfunction." + ] + }, + { + "id": "multiclinsum_test_1314_en.txt", + "fulltext": "A 60 years-old man was referred to our department due to painless gross hematuria. The patient had no risk factors including smoking, previous radiation therapy, occupational risk factors or hereditary factors. In addition, no other pre-existing conditions were known. The patient was painless and did not have any B-symptoms including weight loss or night sweats, furthermore, no neurological deficits were reported.\nAfter exclusion of urinary infection as cause for hematuria, cystoscopy has been performed revealing a 6 cm solid tumor on the right bladder wall. Urinary cytology (voided urine and bladder washing) remained negative.\nConsequently, a transurethral resection of the tumor has been performed and the tumor was macroscopically totally removed. Primary histology of the tumor specimen showed a muscle invasive small cell neuroendocrine carcinoma pT2a GIII. Moreover, tumor cells were positive for synaptophysin and AE1/AE3, with a high proliferation rate (KI-67) of 95 % on immunohistochemical analysis . In contrast, chromogranin A, CD56, CD3, CD20, TdT, S-100 and HMB45 confirmed negative staining.\n18 FDG-positron emission tomography/computed tomography (PET/CT) performed at the time of primary diagnosis did not show any lymph node or visceral metastatic tumor spread. A subsequent cranial magnet resonance tomography (MRT) also confirmed no tumor infiltration into the brain.\nAs there are reports of increased survival rates upon neoadjuvant chemotherapy in patients suffering from SCBC , the patient underwent four cycles (day 1–3; 1 cycle = 21 days) of cisplatin (25 mg/m2)/etoposide (100 mg/m2) without any complications. In addition, we performed a prophylactic WBRT with a total dose of 26 Gray. Subsequently, the patient underwent radical cystoprostatectomy and ileal neobladder with bilateral extended pelvic lymphadenectomy (including 32 resected tumor-free lymph nodes). Final pathology confirmed complete response to neoadjuvant chemotherapy, with no vital small cell carcinoma tissue formations in both the lymph nodes and the cystoprostatectomy specimen (ypT0, N0, L0, V0, Pn0). An uneventful intra- and postoperative course was observed. The time from transurethral resection to chemotherapy start was 28 days. 34 days after chemotherapy was stopped, radical cystoprostatectomy has been performed.\nCurrently, the patient undergoes 6-monthly regular follow-up controls including urinary cytology (voided urine), measurement of residual urine, blood gas analysis and imaging studies (chest/abdominal CT scan every second visit or chest radiography in combination with abdominal ultrasound). We noticed no evidence for relapse, even 33 months after initial diagnosis of SCBC.", + "fulltext_subclaims": [ + "The patient was a 60 years-old man.", + "The patient was referred due to painless gross hematuria.", + "The patient had no risk factors including smoking, previous radiation therapy, occupational risk factors or hereditary factors.", + "The patient was painless and did not have any B-symptoms including weight loss or night sweats.", + "Cystoscopy revealed a 6 cm solid tumor on the right bladder wall.", + "Urinary cytology (voided urine and bladder washing) remained negative.", + "A transurethral resection of the tumor has been performed.", + "The tumor was macroscopically totally removed.", + "Primary histology showed a muscle invasive small cell neuroendocrine carcinoma pT2a GIII.", + "Tumor cells were positive for synaptophysin and AE1/AE3.", + "The KI-67 proliferation rate was 95 %.", + "Chromogranin A, CD56, CD3, CD20, TdT, S-100 and HMB45 confirmed negative staining.", + "18 FDG-PET/CT did not show any lymph node or visceral metastatic tumor spread.", + "Cranial MRT confirmed no tumor infiltration into the brain.", + "The patient underwent four cycles of cisplatin (25 mg/m2)/etoposide (100 mg/m2).", + "The patient underwent prophylactic WBRT with a total dose of 26 Gray.", + "The patient underwent radical cystoprostatectomy and ileal neobladder with bilateral extended pelvic lymphadenectomy.", + "Final pathology confirmed complete response to neoadjuvant chemotherapy.", + "There were no vital small cell carcinoma tissue formations in both the lymph nodes and the cystoprostatectomy specimen.", + "The time from transurethral resection to chemotherapy start was 28 days.", + "Radical cystoprostatectomy was performed 34 days after chemotherapy was stopped.", + "The patient undergoes 6-monthly regular follow-up controls.", + "There was no evidence for relapse 33 months after initial diagnosis of SCBC." + ], + "summary": "We present an unusual long term disease free survival of a 60 year-old man who was diagnosed with SCBC two and a half years ago. He underwent four cycles of cisplatin/etoposide chemotherapy as well as a prophylactic whole-brain radiotherapy followed by a radical cystoprostatectomy and ileal neobladder with extended pelvic lymphadenectomy. Since 33 months the patient is now recurrence-free.", + "summary_subclaims": [ + "The patient is a 60 year-old man.", + "The patient was diagnosed with SCBC two and a half years ago.", + "The patient underwent four cycles of cisplatin/etoposide chemotherapy.", + "The patient underwent prophylactic whole-brain radiotherapy.", + "The patient had a radical cystoprostatectomy.", + "The patient had an ileal neobladder.", + "The patient had an extended pelvic lymphadenectomy.", + "The patient is now recurrence-free since 33 months." + ] + }, + { + "id": "multiclinsum_test_1302_en.txt", + "fulltext": "A 46-year-old male with end-stage renal disease of unknown cause had been on hemodialysis for 3 years when he underwent cadaveric renal transplantation 15 months ago. Except for 3 years of hypertension, there was no other remarkable medical history. The kidneys of donor after brain death were procured by an operation group. However, during harvesting of the donor’s kidneys, a branch of right renal artery to renal superior polar was inadvertently cut off. The artery branch with a diameter 0.3 mm arised from the bifurcation of abdominal aorta and renal artery. Subsequently the severed renal artery branch was anastomosed in situ with 7–0 prolene during the repair of the kidney. Although the lengh of the renal artery branch became little shorter, the major trunk of renal artery was not excessively stretched. The cold and warm ischemia time of the kidney were 5 min and 6 h respectively. The right kidney of donor was transplanted in the right iliac fossa. The donor renal artery with a Carrel patch of donor aorta was anastomosed end-to-side to the recipient right external iliac artery with 6–0 prolene, and renal vein was anastomosed end-to-side to the recipient right external iliac vein with 5–0 prolene, and the graft ureter was anastomosed to the urinary bladder of the recipient with a double J stent. Basiliximab was used as immunity induction on the day of surgery and the fourth day after transplantation. His immunosuppression regimen consisted of tacrolimus, mycophenolate sodium, and prednisolone. His immediate postoperative course was unremarkable. His blood pressure was controlled to 140–156/90–105 mmHg with nicardipine spironolactone, and furosemide y. The 24-h urine volume was between 1937 and 4100 ml, and his renal function. Significantly improved, reaching a creatinine of 151 μmol/L on 11st day posttransplantation. However, from the 12nd day after transplantation his blood pressure began to gradually increase to 170–174/103-109 mmHg.There was no positive presentation on clinical examination and ultrasonograph, and the level of creatinine and urine volume were also stable. So the nicardipine was increased. To our surprise, it was still difficult to control his blood pressure even though three antihypertensive medications (sustained-release nifedipine 60 mg twice daily, urapidil 30 mg twice daily, arotinolol 10 mg twice daily) were administrated. His blood pressure reached to 190/120 mmHg on 20th day after transplantation. There was a decrease in 24-h urine volume with 1620-1725 ml, and mild impairment of renal function with a creatinine of 194 μmol/L. A bruit became audible over the site of the transplanted kidney. Color Doppler ultrasonography indicated a decreased RI in intrarenal arteries and increased blood flow of the transplant renal artery, with RI of 0.45, the peak systolic velocity(PSV) of 305 cm/s and the velocity gradient between stenotic and prestenotic segment of more than 3:1, therefore, a vascular complication of TRAS was suspected. Diagnostic arteriography was performed through a retrograde contralateral femoral artery puncture on 22nd day after transplantation, and it showed a 90% stenosis of transplant renal artery, and the TRAS occurred in the distal site of the anastomosis instead of the anastomosis . We considered that the reconstructional renal artery branch stretched the trunk of renal artery, which resulted in the stenosis distal to the suture line. Two days later, after sufficient preparation renal artery angioplasty was undertaken through a retrograde ipsilateral femoral artery approach. As the stenosis might be high elastic due to the stretch, percutaneous transluminal stent implantation was performed. Because the artery branch situated on the stenosis, bare stent (6 × 14 mm, Express Vascular SD) had to be chosen to avoid effecting the flow of the artery branch. After the bare stent was successfully deployed, a second angiographic evaluation verified the effectiveness of the intervention was obvious. After the interventional treatment, the renal function and urine volume recovered, and his blood pressure was stably controlled to 121/80 mmHg with only two antihypertension (nifedipine and arotinolol). He was discharged on 28 day after transplantation with a creatinine of 108 μmol/L. Changes in clinical parameters over the 1-month treatment period is shown in Table . The patient’s renal function remains stable at clinical follow-up of 15 months.", + "fulltext_subclaims": [ + "The patient was a 46-year-old male with end-stage renal disease of unknown cause.", + "He had been on hemodialysis for 3 years.", + "He underwent cadaveric renal transplantation 15 months ago.", + "There was no other remarkable medical history except for 3 years of hypertension.", + "The donor was after brain death.", + "During harvesting of the donor’s kidneys, a branch of right renal artery to renal superior polar was inadvertently cut off.", + "The artery branch with a diameter 0.3 mm arose from the bifurcation of abdominal aorta and renal artery.", + "The severed renal artery branch was anastomosed in situ with 7–0 prolene during the repair of the kidney.", + "The cold ischemia time of the kidney was 5 min.", + "The warm ischemia time of the kidney was 6 h.", + "The right kidney of donor was transplanted in the right iliac fossa.", + "The donor renal artery with a Carrel patch of donor aorta was anastomosed end-to-side to the recipient right external iliac artery with 6–0 prolene.", + "The renal vein was anastomosed end-to-side to the recipient right external iliac vein with 5–0 prolene.", + "The graft ureter was anastomosed to the urinary bladder of the recipient with a double J stent.", + "Basiliximab was used as immunity induction on the day of surgery and the fourth day after transplantation.", + "His immunosuppression regimen consisted of tacrolimus, mycophenolate sodium, and prednisolone.", + "His immediate postoperative course was unremarkable.", + "His blood pressure was controlled to 140–156/90–105 mmHg with nicardipine, spironolactone, and furosemide.", + "The 24-h urine volume was between 1937 and 4100 ml.", + "His renal function significantly improved, reaching a creatinine of 151 μmol/L on 11st day posttransplantation.", + "From the 12nd day after transplantation, his blood pressure began to gradually increase to 170–174/103–109 mmHg.", + "There was no positive presentation on clinical examination and ultrasonography.", + "The level of creatinine and urine volume were also stable.", + "Nicardipine was increased.", + "It was still difficult to control his blood pressure even though three antihypertensive medications were administered.", + "His blood pressure reached 190/120 mmHg on 20th day after transplantation.", + "There was a decrease in 24-h urine volume with 1620–1725 ml.", + "There was mild impairment of renal function with a creatinine of 194 μmol/L.", + "A bruit became audible over the site of the transplanted kidney.", + "Color Doppler ultrasonography indicated a decreased RI in intrarenal arteries.", + "Color Doppler ultrasonography indicated increased blood flow of the transplant renal artery.", + "The RI was 0.45.", + "The peak systolic velocity was 305 cm/s.", + "The velocity gradient between stenotic and prestenotic segment was more than 3:1.", + "A vascular complication of TRAS was suspected.", + "Diagnostic arteriography showed a 90% stenosis of transplant renal artery.", + "The TRAS occurred in the distal site of the anastomosis instead of the anastomosis.", + "We considered that the reconstructional renal artery branch stretched the trunk of renal artery, which resulted in the stenosis distal to the suture line.", + "Renal artery angioplasty was undertaken through a retrograde ipsilateral femoral artery approach.", + "Percutaneous transluminal stent implantation was performed.", + "A bare stent (6 × 14 mm, Express Vascular SD) had to be chosen to avoid affecting the flow of the artery branch.", + "After the bare stent was successfully deployed, a second angiographic evaluation verified the effectiveness of the intervention was obvious.", + "After the interventional treatment, the renal function and urine volume recovered.", + "His blood pressure was stably controlled to 121/80 mmHg with only two antihypertension medications (nifedipine and arotinolol).", + "He was discharged on 28 day after transplantation with a creatinine of 108 μmol/L.", + "The patient’s renal function remains stable at clinical follow-up of 15 months." + ], + "summary": "A 46-year-old male with end-stage renal disease of unknown cause received a cadaveric renal transplant one year ago. Although three antihypertensive medications were administrated, his blood pressure gradually increased to 190/120 mmHg 3 weeks posttransplantation. Also the level of creatinine increased to 194 μmol/L.Color Doppler ultrasonography indicated a decreased resistance index (RI) in intrarenal arteries and increased blood flow of the transplant renal artery, therefore, a vascular complication of TRAS was suspected. Arteriography was performed and demonstrated TRAS caused by stretch of an artery branch, and the TRAS occurred in the distal site of the anastomosis instead of the anastomosis. Percutaneous transluminal bare stent implantation treatment was successfully performed. Satisfactory clinical efficacy with improvement in transplant renal function and renovascular hypertension was achieved after the interventional treatment.", + "summary_subclaims": [ + "The patient is a 46-year-old male.", + "The patient has end-stage renal disease of unknown cause.", + "The patient received a cadaveric renal transplant one year ago.", + "Three antihypertensive medications were administrated.", + "His blood pressure increased to 190/120 mmHg 3 weeks posttransplantation.", + "The level of creatinine increased to 194 μmol/L.", + "Color Doppler ultrasonography indicated a decreased resistance index in intrarenal arteries.", + "Color Doppler ultrasonography indicated increased blood flow of the transplant renal artery.", + "A vascular complication of TRAS was suspected.", + "Arteriography was performed.", + "TRAS occurred in the distal site of the anastomosis instead of the anastomosis.", + "Percutaneous transluminal bare stent implantation treatment was successfully performed.", + "Satisfactory clinical efficacy with improvement in transplant renal function was achieved after the interventional treatment.", + "Satisfactory clinical efficacy with improvement in renovascular hypertension was achieved after the interventional treatment." + ] + }, + { + "id": "multiclinsum_test_590_en.txt", + "fulltext": "The patient, a 32-year-old female, was admitted to the hospital on May 17th, 2023 at 15:51 with a chief complaint of “cough for 7 days, aggravated with hemoptysis for 9 hours.” She had a past medical history of Hashimoto thyroiditis, which was not systematically treated. She had had a cough for 7 days, which began to worsen 9 hours prior to admission, accompanied by 100 milliliters of blood. Chest computed tomography (CT) showed: (1) bilateral pneumonia with alveolar hemorrhage was considered, and reexamination was recommended after treatment. (2) Multiple bronchial mucus sputum plugs were found in the right main bronchus and the middle and lower lobes of the right lung . In the afternoon of the same day, the patient developed hemoptysis again, with a large amount of fresh blood and a little blood clot. Physical examination: temperature: 36.2 °C, pulse: 128 beats/min, respiration: 25 breaths/min, blood pressure: 75/49 mm Hg, fingertip oxygen saturation: 50%. The breath sounds in the right lung were weak, while obvious moist rales were heard in the left lung.", + "fulltext_subclaims": [ + "The patient is a 32-year-old female.", + "She was admitted to the hospital on May 17th, 2023 at 15:51.", + "Her chief complaint was a cough for 7 days.", + "The cough was aggravated with hemoptysis for 9 hours.", + "She had a past medical history of Hashimoto thyroiditis.", + "The Hashimoto thyroiditis was not systematically treated.", + "Chest computed tomography showed bilateral pneumonia with alveolar hemorrhage was considered.", + "Reexamination after treatment was recommended.", + "Multiple bronchial mucus sputum plugs were found in the right main bronchus.", + "Multiple bronchial mucus sputum plugs were found in the middle and lower lobes of the right lung.", + "In the afternoon of the same day, the patient developed hemoptysis again.", + "The hemoptysis was accompanied by a large amount of fresh blood.", + "The hemoptysis was accompanied by a little blood clot.", + "Physical examination showed a blood pressure of 75/49 mm Hg.", + "Physical examination showed fingertip oxygen saturation of 50%." + ], + "summary": "We report a 32-year-old female who experienced cough, accompanied by fatal massive hemoptysis with extensive blood clot obstruction in the airway. Considering the difficulty of clearing the airway using conventional methods, it was decided to perform fiberoptic bronchoscopy combined with urokinase therapy after reviewing relevant literature. After treatment, the intrapulmonary blood clots were successfully extracted, thereby relieving airway obstruction. Finally, the patient was successfully weaned off extracorporeal membrane oxygenation, extubated, and evacuated from the ventilator. Currently, the patient's condition is stable, and follow-up chest X-ray as well as computed tomography scans have shown improvement compared to previous assessments.", + "summary_subclaims": [ + "The patient was a 32-year-old female.", + "The patient experienced cough.", + "The patient experienced fatal massive hemoptysis.", + "There was extensive blood clot obstruction in the airway.", + "It was difficult to clear the airway using conventional methods.", + "Fiberoptic bronchoscopy combined with urokinase therapy was decided after reviewing relevant literature.", + "Intrapulmonary blood clots were successfully extracted.", + "Airway obstruction was relieved.", + "The patient was successfully weaned off extracorporeal membrane oxygenation.", + "The patient was extubated.", + "The patient was evacuated from the ventilator.", + "The patient's condition is currently stable.", + "Follow-up chest X-ray showed improvement compared to previous assessments.", + "Computed tomography scans showed improvement compared to previous assessments." + ] + }, + { + "id": "multiclinsum_test_1372_en.txt", + "fulltext": "A 67-year-old woman underwent PBSCT for therapy-related acute myeloid leukaemia and received azacitidine, busulfan and fludarabine therapy. Before PBSCT, she had been diagnosed with resolved HBV infection; HBsAg, negative; hepatitis B core antibody (HBcAb), positive (180.6 C.O.I.); and hepatitis B surface antibody (HBsAb), positive (36.9 mIU/mL). She had no history of HBV vaccination, but she experienced acute hepatitis B caused by blood transfusion for her child birth before PBSCT. Changes in HBsAb and HBcrAg during the course are presented in Fig. , as well as other liver function and viral status, alanine aminotransferase (ALT), HBsAg, HBcAb, HBeAg, hepatitis B e antibody (HBeAb) and HBV-DNA levels. Serum HBcrAg levels were determined via chemiluminescent enzyme immunoassay (LUMIPULSE®, Fujirebio Inc., Tokyo, Japan).\nShe received rituximab for post-transplant lymphoproliferative disorder 26 months after PBSCT, her HBsAb decreased (8.6 mIU/mL) and HBV-DNA increased slightly to detectable though the levels of < 1.3 logIU/mL. Since she tested positive for HBV-DNA (1.4 logIU/mL) 103 days after the first rituximab therapy (day 0, Fig. H), the scheduled rituximab administration was skipped and the first entecavir treatment was started according to the Japanese guideline for HBV reactivation . Immediately after the first entecavir treatment, the HBV-DNA test became negative (day 63, Fig. H). Since her liver function (ALT levels) had been normal and both HBsAg and HBV-DNA remained negative during NA treatment , entecavir was terminated on day 376. According to the retrospective measurements, HBcrAg remained positive (3.6–3.9 logU/mL) while the HBV-DNA level was undetectable under the first entecavir treatment (day 63–455, Fig. D). One hundred forty-one days after entecavir cessation, the HBV-DNA test turned positive again (1.8 logIU/mL), suggesting HBV rebound (day 517). Her HBV-DNA level reached 5.2 logIU/mL (day 601, Fig. H), her liver function deteriorated and HBV infection worsened; ALT, HBsAg, HBcrAg, HBcAb and HBeAg were elevated to high levels at 280 U/L, 1101.8 IU/mL, 7.0 logU/mL (above the detection range), 727.3 C.O.I. and 1060 S/CO, respectively (day 658, Fig. A, B, D, E and F), even though entecavir treatment was resumed on day 615. The HBsAb level, which had been negative before the HBV rebound, further decreased (0.3 mIU/mL) when the HBV rebound was detected . ALT peaked at 455 U/L on day 685 when the levels for HBsAg, HBcrAg, HBeAg and HBV-DNA peaked out and declined . On the contrary, HBsAb and HBeAb levels increased to 292.8–1631.6 mIU/mL and 99.2–99.5%, respectively , after the rebound, resulting in HBsAg seroconversion with HBcrAg and HBV-DNA levels undetectable. The second entecavir treatment was terminated on day 986. HBV reactivation has not been detected 392 days after the second entecavir cessation, and both HBcrAg and HBV-DNA levels remained undetectable. No difference in medication adherence and renal function was observed between first and second entecavir treatment. Daily dose of entecavir was 0.5 mg for both first and second treatment.", + "fulltext_subclaims": [ + "The patient is a 67-year-old woman.", + "She underwent PBSCT for therapy-related acute myeloid leukaemia.", + "She received azacitidine, busulfan, and fludarabine therapy.", + "Before PBSCT, she had been diagnosed with resolved HBV infection.", + "HBsAg was negative before PBSCT.", + "HBcAb was positive (180.6 C.O.I.) before PBSCT.", + "HBsAb was positive (36.9 mIU/mL) before PBSCT.", + "She had no history of HBV vaccination.", + "She experienced acute hepatitis B caused by blood transfusion for her childbirth before PBSCT.", + "HBsAb decreased to 8.6 mIU/mL after rituximab therapy.", + "HBV-DNA increased slightly to detectable levels (< 1.3 logIU/mL) after rituximab therapy.", + "HBV-DNA was 1.4 logIU/mL 103 days after the first rituximab therapy.", + "The scheduled rituximab administration was skipped.", + "The first entecavir treatment was started according to the Japanese guideline for HBV reactivation.", + "HBV-DNA became negative immediately after the first entecavir treatment.", + "Entecavir was terminated on day 376.", + "HBcrAg remained positive (3.6–3.9 logU/mL) during the first entecavir treatment.", + "HBV-DNA was undetectable under the first entecavir treatment.", + "HBV-DNA turned positive again 141 days after entecavir cessation.", + "HBV-DNA reached 5.2 logIU/mL.", + "ALT levels peaked at 455 U/L.", + "HBsAg was 1101.8 IU/mL.", + "HBcrAg was 7.0 logU/mL.", + "HBcAb was 727.3 C.O.I.", + "HBeAg was 1060 S/CO.", + "HBsAb was 0.3 mIU/mL when HBV rebound was detected.", + "HBsAb increased to 292.8–1631.6 mIU/mL after the rebound.", + "HBeAb increased to 99.2–99.5% after the rebound.", + "HBsAg seroconversion occurred.", + "HBcrAg and HBV-DNA levels were undetectable after seroconversion.", + "The second entecavir treatment was terminated on day 986.", + "HBV reactivation has not been detected 392 days after the second entecavir cessation.", + "HBcrAg and HBV-DNA levels remained undetectable after the second entecavir cessation." + ], + "summary": "A 67-year-old woman with resolved HBV infection received rituximab for post-transplant lymphoproliferative disorder after peripheral blood stem cell transplantation. Since she tested positive for HBV-DNA after the first rituximab therapy (day 0), entecavir treatment was started. Because the HBV-DNA test became negative and her liver function had been normal, entecavir was terminated on day 376. According to the retrospective measurements, HBcrAg remained positive while the HBV-DNA level was undetectable. One hundred forty-one days after entecavir cessation, the HBV-DNA turned positive again, suggesting HBV rebound (day 517). Her liver function deteriorated and HBV infection worsened, even though entecavir treatment was resumed on day 615. On the contrary, hepatitis B surface antibody levels increased after the rebound, resulting in HBsAg seroconversion with HBcrAg and HBV-DNA levels undetectable. HBV reactivation has not been detected after the second entecavir cessation, and both HBcrAg and HBV-DNA levels remained undetectable.", + "summary_subclaims": [ + "The patient is a 67-year-old woman.", + "She has a resolved HBV infection.", + "She received rituximab for post-transplant lymphoproliferative disorder.", + "She had a peripheral blood stem cell transplantation.", + "She tested positive for HBV-DNA after the first rituximab therapy.", + "Entecavir treatment was started.", + "HBV-DNA test became negative.", + "Her liver function had been normal.", + "Entecavir was terminated on day 376.", + "HBcrAg remained positive.", + "HBV-DNA level was undetectable.", + "One hundred forty-one days after entecavir cessation, HBV-DNA turned positive again.", + "HBV-DNA turned positive again on day 517.", + "HBV rebound is suggested.", + "Her liver function deteriorated.", + "HBV infection worsened.", + "Entecavir treatment was resumed on day 615.", + "Hepatitis B surface antibody levels increased after the rebound.", + "HBsAg seroconversion occurred.", + "HBcrAg levels were undetectable.", + "HBV-DNA levels were undetectable.", + "HBV reactivation has not been detected after the second entecavir cessation." + ] + }, + { + "id": "multiclinsum_test_1973_en.txt", + "fulltext": "A 54-year-old woman with a 10-year history of a reversible bulge in her right sacrococcygeal region presented to our outpatient clinic.\nThe bulge disappeared in the prone position and appeared when standing. In addition, she complained of long-term constipation. There was no regional or abdominal pain, no nausea and vomiting, and no abdominal distention in her course of disease. In the past ten years, she had not received any relevant examination or treatment. Noticing that the bulge was increasing in size gradually, she came to seek treatment and then was admitted to our inpatient ward.\nThe patient denied a history of chronic diseases or infectious diseases. She had a history of caesarean section 17 years ago but no trauma or blood transfusion. She also had no known drug or food allergies.\nA bulge in the right sacrococcygeal region was revealed upon standing, which was approximately 8 cm × 8 cm in size and soft in palpation with no tenderness . In the prone position, the bulge returned spontaneously but relapsed when performing the Valsalva manoeuvre. The abdomen was flat, with an old surgical scar in the hypogastric zone.\nLaboratory examinations performed in the ward included routine blood tests and biochemistry examinations. All results were within normal limits.\nDoppler ultrasound detected a bulge in the bowel when there was an increase in abdominal pressure, which returned to the abdominal cavity after loosening. Computed tomography confirmed the Doppler ultrasound finding of rectal herniation and displayed an abnormality in the structure of the tissues between the midline of the sacrococcygeal region and the right gluteus muscle .", + "fulltext_subclaims": [ + "The patient is a 54-year-old woman.", + "She has a 10-year history of a reversible bulge in her right sacrococcygeal region.", + "The bulge disappeared in the prone position and appeared when standing.", + "She complained of long-term constipation.", + "There was no regional or abdominal pain.", + "There was no nausea and vomiting.", + "There was no abdominal distention in her course of disease.", + "In the past ten years, she had not received any relevant examination or treatment.", + "The patient denied a history of chronic diseases or infectious diseases.", + "She had a history of caesarean section 17 years ago.", + "She had no trauma or blood transfusion.", + "She had no known drug or food allergies.", + "A bulge in the right sacrococcygeal region was revealed upon standing.", + "The bulge was approximately 8 cm × 8 cm in size.", + "The bulge was soft in palpation with no tenderness.", + "The bulge returned spontaneously in the prone position.", + "The bulge relapsed when performing the Valsalva manoeuvre.", + "The abdomen was flat.", + "There was an old surgical scar in the hypogastric zone.", + "Laboratory examinations included routine blood tests and biochemistry examinations.", + "All laboratory results were within normal limits.", + "Doppler ultrasound detected a bulge in the bowel when there was an increase in abdominal pressure.", + "The bulge returned to the abdominal cavity after loosening.", + "Computed tomography confirmed the Doppler ultrasound finding of rectal herniation.", + "Computed tomography displayed an abnormality in the structure of the tissues between the midline of the sacrococcygeal region and the right gluteus muscle." + ], + "summary": "A 54-year-old woman who chiefly complained of a 10-year history of a reversible bulge in her right sacrococcygeal region was admitted to our hospital. The physical examination revealed a bulge in the right sacrococcygeal region upon standing, which disappeared in the prone position but relapsed when performing the Valsalva manoeuvre. Computed tomography displayed an abnormality in the structure of the tissues between the midline of the sacrococcygeal region and the right gluteus muscle. The patient was diagnosed with sacrococcygeal hernia and received hernia repair with mesh through a combined laparoscopic and sacrococcygeal approach. On laparoscopy, the rectum was dissected posterolaterally, and a defect was identified in the right anterior sacrococcygeal region through which part of the rectum protruded. This was followed by the placement of a self-gripping polyester mesh via a sacrococcygeal approach. There were no postoperative complications. The patient was discharged on postoperative day 7 and was followed for more than 6 mo with no recurrence.", + "summary_subclaims": [ + "The patient was a 54-year-old woman.", + "She had a 10-year history of a reversible bulge in her right sacrococcygeal region.", + "The physical examination revealed a bulge in the right sacrococcygeal region upon standing.", + "The bulge disappeared in the prone position.", + "The bulge relapsed when performing the Valsalva manoeuvre.", + "Computed tomography displayed an abnormality in the structure of the tissues between the midline of the sacrococcygeal region and the right gluteus muscle.", + "The patient was diagnosed with sacrococcygeal hernia.", + "The patient received hernia repair with mesh through a combined laparoscopic and sacrococcygeal approach.", + "On laparoscopy, the rectum was dissected posterolaterally.", + "A defect was identified in the right anterior sacrococcygeal region through which part of the rectum protruded.", + "A self-gripping polyester mesh was placed via a sacrococcygeal approach.", + "There were no postoperative complications.", + "The patient was discharged on postoperative day 7.", + "The patient was followed for more than 6 mo with no recurrence." + ] + }, + { + "id": "multiclinsum_test_796_en.txt", + "fulltext": "When a 33-YEAR-OLD woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. She had no remarkable medical history. The fire department dispatched an ambulance and requested the DH be dispatched after receiving an emergency call. After the DH equipped with the portable X-ray system landed at the rendezvous zone, the staff were sent by fire truck to the accident scene. When the staff of the DH checked the patient at the scene, her vital signs were as follows: Glasgow Coma Scale, E4V5M6; systolic blood pressure, 110/66 mmHg; pulse rate, 77 b.p.m.; percutaneous oxygen saturation, 100% under room air; respiratory rate, 20 breaths/min. She had mild posterior neck tenderness and pelvic tenderness with a seat belt mark. The findings of a focused assessment with sonography for trauma, chest X-ray, and pelvic X-ray in the ambulance, after the patient verbally confirmed that she was not pregnant, were all negative . She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance staffed only with emergency medical technicians.", + "fulltext_subclaims": [ + "A 33-year-old woman was driving a car when it hit another car at a crossroad.", + "The car tipped onto its side after the collision.", + "The woman had no remarkable medical history.", + "The fire department dispatched an ambulance and requested the DH be dispatched after receiving an emergency call.", + "The DH equipped with a portable X-ray system landed at the rendezvous zone.", + "Staff were sent by fire truck to the accident scene.", + "At the scene, the patient's Glasgow Coma Scale was E4V5M6.", + "The patient's systolic blood pressure was 110 mmHg.", + "The patient's diastolic blood pressure was 66 mmHg.", + "The patient's pulse rate was 77 b.p.m.", + "The patient's percutaneous oxygen saturation was 100% under room air.", + "The patient's respiratory rate was 20 breaths/min.", + "The patient had mild posterior neck tenderness.", + "The patient had pelvic tenderness with a seat belt mark.", + "A focused assessment with sonography for trauma was performed in the ambulance.", + "A chest X-ray was performed in the ambulance.", + "A pelvic X-ray was performed in the ambulance.", + "The patient verbally confirmed that she was not pregnant.", + "The findings of the focused assessment with sonography for trauma were negative.", + "The findings of the chest X-ray were negative.", + "The findings of the pelvic X-ray were negative.", + "The patient received a diagnosis of cervical sprain.", + "The patient received a diagnosis of pelvic contusion.", + "The patient was transferred to a local hospital by ambulance staffed only with emergency medical technicians." + ], + "summary": "When a 33-year-old woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. Staff of the doctor helicopter checked her at the scene, and the findings of chest and pelvic X-ray were all negative. She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance.", + "summary_subclaims": [ + "A 33-year-old woman was driving a car when she made a right turn at a crossroad.", + "Her car hit another car, causing her vehicle to tip onto its side.", + "Staff of the doctor helicopter checked her at the scene.", + "The findings of chest and pelvic X-ray were all negative.", + "She received a diagnosis of cervical sprain.", + "She received a diagnosis of pelvic contusion.", + "She was transferred to a local hospital by ambulance." + ] + }, + { + "id": "multiclinsum_test_2788_en.txt", + "fulltext": "The patient was a one-day-old boy with a prenatally diagnosed omphalocele. A 34-year-old pregnant mother was referred to our hospital at 17 weeks (approximately 4 months) of gestation with the chief concern of a singleton fetus with a 30 mm (approximately 1.18 in.) cystic lesion near the umbilical cord base. A fetal magnetic resonance image (MRI) scan (25 weeks of gestation) revealed a 30 × 33 mm (approximately 1.3 in.) cystic lesion as shown in Fig. which was suspected to be an umbilical cyst. A follow-up MRI (at 34 weeks) revealed an umbilical cord hernia instead of a cystic lesion. The baby was born vaginally at 38 weeks, weighing 2956 g, with APGAR scores of 8 and 9 at 1 and 5 min, respectively. An omphalocele (hernial orifice diameter, 4 cm × 3 cm) with bladder prolapse was recognized as shown in Fig. . Based on appearance of umbilical site, physical examination and abdominal ultrasonography, the patient was diagnosed with a small omphalocele with bladder evagination. The small intestine prolapsed only while straining associated with crying, however, this was minimal, and we estimated that there would be low risk for hernia incarceration. So we planned the surgery for omphalocele with bladder evagination 1 day after birth.\nUnder general anesthesia, the patient was placed in supine position. After hernia sac excision, the intestine was naturally reducible and there were no other structural anomalies. In order to secure sufficient bladder volume, we estimated the minimum residual volume as 21 ml after bladder plasty. For bladder capacity, the simplified formula: Capacity (mL) = 7 × weight (kg) was a reliable estimate of expected bladder capacity in infants independent of age . As shown in Fig. a, 8Fr. tube (Atom Multipurpose Tube, Atom Medical Corp, Tokyo, Japan) was inserted and the bladder was clamped as the maximum residual volume remained. And then clamped bladder was confirmed to be kept within the abdominal cavity. The bladder volume was also confirmed to be 30 ml using contrast medium. After the resection line was determined as shown in Fig. b, partial cystectomy was performed. The prolapsed bladder was resected and closed with two-layer continuous sutures with 4-0 PDS. The actual remaining bladder capacity was confirmed to be 30 ml by injecting a contrast dye and saline into the bladder. The patient had no associated cardiac, urogenital or skeletal anomalies. On pathological examination, bladder wall which was composed of mucosa and muscular layer was detected in the entire resected specimen.\nPostoperative course was uneventful. He was regularly followed up for 2 years after surgery , and underwent umbilicoplasty at 2 years old of age . He had no trouble with urinary function.", + "fulltext_subclaims": [ + "The patient was a one-day-old boy with a prenatally diagnosed omphalocele.", + "A 34-year-old pregnant mother was referred to our hospital at 17 weeks of gestation with the chief concern of a singleton fetus with a 30 mm cystic lesion near the umbilical cord base.", + "A fetal MRI scan at 25 weeks of gestation revealed a 30 × 33 mm cystic lesion suspected to be an umbilical cyst.", + "A follow-up MRI at 34 weeks revealed an umbilical cord hernia instead of a cystic lesion.", + "The baby was born vaginally at 38 weeks, weighing 2956 g.", + "The APGAR scores were 8 at 1 min and 9 at 5 min.", + "An omphalocele with hernial orifice diameter 4 cm × 3 cm and bladder prolapse was recognized.", + "The patient was diagnosed with a small omphalocele with bladder evagination.", + "The small intestine prolapsed only while straining associated with crying.", + "The estimated risk for hernia incarceration was low.", + "Surgery for omphalocele with bladder evagination was planned 1 day after birth.", + "The patient was placed in supine position under general anesthesia.", + "The hernia sac was excised.", + "The intestine was naturally reducible.", + "There were no other structural anomalies.", + "The simplified formula: Capacity (mL) = 7 × weight (kg) was a reliable estimate of expected bladder capacity in infants independent of age.", + "An 8Fr. tube was inserted into the bladder.", + "The bladder was clamped as the maximum residual volume remained.", + "The clamped bladder was confirmed to be kept within the abdominal cavity.", + "The bladder volume was confirmed to be 30 ml using contrast medium.", + "Partial cystectomy was performed.", + "The prolapsed bladder was resected and closed with two-layer continuous sutures with 4-0 PDS.", + "The actual remaining bladder capacity was confirmed to be 30 ml by injecting a contrast dye and saline into the bladder.", + "The patient had no associated cardiac, urogenital, or skeletal anomalies.", + "On pathological examination, bladder wall composed of mucosa and muscular layer was detected in the entire resected specimen.", + "The postoperative course was uneventful.", + "The patient was regularly followed up for 2 years after surgery.", + "The patient underwent umbilicoplasty at 2 years old.", + "The patient had no trouble with urinary function." + ], + "summary": "We encountered a small omphalocele with bladder evagination associated with urachal aplasia for which the neonate underwent surgery one day after birth. The patient was a one-day-old boy with a prenatally diagnosed omphalocele. A fetal magnetic resonance image (MRI) scan (25 weeks of gestation) revealed a 30 × 33 mm (approximately 1.3 in.) cystic lesion which was suspected to be an umbilical cyst. The baby was born vaginally at 38 weeks, weighing 2956 g. An omphalocele (hernial orifice diameter, 4 cm × 3 cm) with bladder prolapse was recognized. After sac excision, the prolapsed bladder was resected and closed with two-layer sutures. In order to secure sufficient bladder capacity, we estimated the minimum residual volume as 21 ml after bladder plasty. The remaining bladder capacity was confirmed to be 30 ml by injecting a contrast dye and saline into the bladder. The neonate had no associated cardiac urogenital or skeletal anomalies. Postoperative course was uneventful. The patient was regularly followed up for two years after surgery and underwent umbilicoplasty. He had no trouble with urinary function.", + "summary_subclaims": [ + "We encountered a small omphalocele with bladder evagination associated with urachal aplasia.", + "The neonate underwent surgery one day after birth.", + "The patient was a one-day-old boy with a prenatally diagnosed omphalocele.", + "A fetal magnetic resonance image (MRI) scan (25 weeks of gestation) revealed a 30 × 33 mm cystic lesion.", + "The cystic lesion was suspected to be an umbilical cyst.", + "The baby was born vaginally at 38 weeks.", + "The baby weighed 2956 g at birth.", + "An omphalocele with a hernial orifice diameter of 4 cm × 3 cm was recognized.", + "The omphalocele had bladder prolapse.", + "After sac excision, the prolapsed bladder was resected and closed with two-layer sutures.", + "We estimated the minimum residual volume as 21 ml after bladder plasty.", + "The remaining bladder capacity was confirmed to be 30 ml by injecting a contrast dye and saline into the bladder.", + "The neonate had no associated cardiac urogenital or skeletal anomalies.", + "The postoperative course was uneventful.", + "The patient was regularly followed up for two years after surgery.", + "The patient underwent umbilicoplasty.", + "He had no trouble with urinary function." + ] + }, + { + "id": "multiclinsum_test_2968_en.txt", + "fulltext": "We report the case of a 42-year-old Tunisian man, born out of a consanguineous marriage, who had no cardiovascular risk factors and was followed-up for hypofibrinogenemia diagnosed three years previously due to bleeding after dental care. He had no known family history of fibrinogen deficiency. He was admitted for an acute typical anginal pain which occurred at rest and continued for several hours.\nOn physical examination he had no fever, his blood pressure was 120/70 mmHg, his heart rate was 65 beats per minute and cardiopulmonary auscultation was normal. An electrocardiogram (ECG) on admission, seven hours after the onset of pain showed an elevation of the ST segment in inferior leads and an ST-segment depression in DI, aVL. His troponin I and creatine phosphokinase levels were elevated to 17 ng/L and 820IU/L respectively. There was no sign of inflammation; his C-reactive protein level was 5 mg/L and white blood cell count, 7000 cells/mL. Bleeding-related tests were carried out. His fibrinogen level was 0.3 g/L using the Von Clauss method, and < 0.16 g/L using the immunological method. His activated partial thromboplastin time was > 120 seconds (control: 32 seconds), prothombin activity < 10% and thrombin time > 120 seconds (control: 13 seconds). His platelet count (242,000/mm3) and bleeding time (140 seconds) were normal. A transthoracic echocardiography estimated his left ventricular ejection fraction at 61% without evidence of segmental motion abnormalities. A coronary angiography was not performed in view of the major risk of bleeding. Cardiac magnetic resonance imaging (MRI) on day 5 showed the presence of almost complete transmural enhancement of the apicolateral segment. It is noteworthy that an etiological investigation for acute myocardial infarction in a young adult was otherwise negative; our patient did not have any protein C or protein S or an antithrombin deficiency; there was neither a Factor V Leiden nor prothrombin G20210 mutation, no anti-phospholipid antibodies (lupus type v inhibitor, anticardiolipin or anti-2-glycoprotein-1 antibodies) were detected and his plasma homocysteine level was normal. His fasting glucose (0.9 g/L) and hemoglobin A1C (4.7%) levels, lipid profile (cholesterol: 1.8 g/L; high density cholesterol: 0.47 g/L; triglycerides: 1.6 g/L; low density cholesterol (Friedewald formula): 1.0 g/L) and liver function tests were also normal. Transesophageal echocardiography ruled out an emboligenic disease. Our patient was managed with aspirin, atenolol, captopril and atorvastatin but did not receive any anticoagulant treatment. He did not experience any angina recurrence.\nA submaximal exercise test on the sixth day was negative. An electrocardiogram on the seventh day showed a Q wave in inferior leads with apicolateral subepicardial ischemia. We did not detect any recurrence of the myocardial ischemia. A cardiac MRI performed one month after the acute episode identified a zone of myocardial necrosis and wall thinning, confirming the initial diagnosis .", + "fulltext_subclaims": [ + "The patient is a 42-year-old Tunisian man.", + "The patient was born out of a consanguineous marriage.", + "The patient had no cardiovascular risk factors.", + "The patient was followed-up for hypofibrinogenemia diagnosed three years previously.", + "The hypofibrinogenemia was diagnosed due to bleeding after dental care.", + "The patient had no known family history of fibrinogen deficiency.", + "The patient was admitted for an acute typical anginal pain.", + "The anginal pain occurred at rest.", + "The anginal pain continued for several hours.", + "On physical examination, the patient had no fever.", + "The patient's blood pressure was 120/70 mmHg.", + "The patient's heart rate was 65 beats per minute.", + "Cardiopulmonary auscultation was normal.", + "An electrocardiogram on admission showed an elevation of the ST segment in inferior leads.", + "An electrocardiogram on admission showed an ST-segment depression in DI, aVL.", + "The patient's troponin I level was elevated to 17 ng/L.", + "The patient's creatine phosphokinase level was elevated to 820IU/L.", + "The patient's C-reactive protein level was 5 mg/L.", + "The patient's white blood cell count was 7000 cells/mL.", + "The patient's fibrinogen level was 0.3 g/L using the Von Clauss method.", + "The patient's fibrinogen level was < 0.16 g/L using the immunological method.", + "The patient's activated partial thromboplastin time was > 120 seconds.", + "The patient's prothrombin activity was < 10%.", + "The patient's thrombin time was > 120 seconds.", + "The patient's platelet count was 242,000/mm3.", + "The patient's bleeding time was 140 seconds.", + "A transthoracic echocardiography estimated the patient's left ventricular ejection fraction at 61%.", + "A coronary angiography was not performed in view of the major risk of bleeding.", + "A cardiac MRI on day 5 showed the presence of almost complete transmural enhancement of the apicolateral segment.", + "An etiological investigation for acute myocardial infarction in a young adult was otherwise negative.", + "The patient did not have any protein C or protein S deficiency.", + "The patient did not have an antithrombin deficiency.", + "There was neither a Factor V Leiden nor prothrombin G20210 mutation.", + "No anti-phospholipid antibodies were detected.", + "The patient's plasma homocysteine level was normal.", + "The patient's fasting glucose level was 0.9 g/L.", + "The patient's hemoglobin A1C level was 4.7%.", + "The patient's cholesterol level was 1.8 g/L.", + "The patient's high density cholesterol level was 0.47 g/L.", + "The patient's triglycerides level was 1.6 g/L.", + "The patient's low density cholesterol level was 1.0 g/L.", + "Transesophageal echocardiography ruled out an emboligenic disease.", + "The patient was managed with aspirin, atenolol, captopril, and atorvastatin.", + "The patient did not receive any anticoagulant treatment.", + "A submaximal exercise test on the sixth day was negative.", + "An electrocardiogram on the seventh day showed a Q wave in inferior leads.", + "An electrocardiogram on the seventh day showed apicolateral subepicardial ischemia.", + "No recurrence of myocardial ischemia was detected.", + "A cardiac MRI performed one month after the acute episode identified a zone of myocardial necrosis.", + "A cardiac MRI performed one month after the acute episode identified wall thinning." + ], + "summary": "A 42-year-old Tunisian man with congenital hypofibrinogenemia and no cardiovascular risk factors presented with new onset prolonged angina pectoris. An electrocardiogram showed features of inferior acute myocardial infarction. His troponin levels had reached 17 ng/L. Laboratory findings confirmed hypofibrinogenemia and ruled out thrombophilia. Echocardiography was not useful in providing diagnostic elements but did show preserved left ventricular function. Coronary angiography was not performed and our patient did not receive any anticoagulant treatment due to the major risk of bleeding. Magnetic resonance imaging confirmed myocardial necrosis. Our patient was managed with aspirin, a beta-blocker, an angiotensin-converting enzyme inhibitor and statin medication. The treatment was well tolerated and no ischemic recurrence was detected.", + "summary_subclaims": [ + "The patient is a 42-year-old Tunisian man.", + "The patient has congenital hypofibrinogenemia.", + "The patient had no cardiovascular risk factors.", + "The patient presented with new onset prolonged angina pectoris.", + "An electrocardiogram showed features of inferior acute myocardial infarction.", + "The patient's troponin levels had reached 17 ng/L.", + "Laboratory findings confirmed hypofibrinogenemia.", + "Laboratory findings ruled out thrombophilia.", + "Echocardiography was not useful in providing diagnostic elements.", + "Echocardiography showed preserved left ventricular function.", + "Coronary angiography was not performed.", + "The patient did not receive any anticoagulant treatment.", + "Magnetic resonance imaging confirmed myocardial necrosis.", + "The patient was managed with aspirin.", + "The patient was managed with a beta-blocker.", + "The patient was managed with an angiotensin-converting enzyme inhibitor.", + "The patient was managed with statin medication.", + "The treatment was well tolerated.", + "No ischemic recurrence was detected." + ] + }, + { + "id": "multiclinsum_test_1727_en.txt", + "fulltext": "A 69-year-old man was hospitalized with transient loss of consciousness due to severe anemia and melena. He had previously suffered from thromboangitis obliterans and had undergone revascularization of his lower extremities. Upper gastrointestinal endoscopy showed two lesions. One 15 mm-sized depressed lesion was present in the lesser curvature of the cardia . Biopsy diagnosed poor differentiated tubular adenocarcinoma. As evaluated by endoscopic ultrasound, the tumor had invaded the submucosa and surgery was necessary. The other lesion was present on the posterior wall of the body in the stomach, and a biopsy of this ulcer scar was diagnosed as suspected gastric cancer . Lower gastrointestinal endoscopy revealed a circumferential type 2 tumor in the sigmoid colon . The tumor was 38 cm from the anal verge. Biopsy revealed moderately differentiated tubular adenocarcinoma. The lumen was narrowed by this tumor, but the scope managed to pass. Preoperative computed tomography (CT) showed no swollen lymph nodes around the gastric lesions. The sigmoid colon had thickened walls and increased concentration of surrounding adipose tissue, but no swollen lymph nodes around the sigmoid colon lesion in preoperative CT . There was no distant metastasis to the gastric cancer or sigmoid colon cancer. Preoperative diagnosis was T1N0M0 Stage I (UICC 8th Edition) for two gastric cancers and T4aN0M0 Stage II B(UICC 8th Edition) for sigmoid colon cancer. The lesion in the body of the stomach was an intramucosal lesion and was singled out for endoscopic treatment, but preoperative treatment was not performed because of a lack of time. The symptoms of sigmoid colon lesions began to appear. We have had a policy of total gastrectomy for removing two gastric cancers.\nPreoperative CT and blood vessel construction using 3D image analysis software SYNAPSE VINCENT® (Fujifilm, Tokyo) showed artificial blood vessels under the skin . There was a bypass vessel from the left axillary artery to the left femoral artery under the skin on the left side of thoracoabdominal region. Furthermore, there were three bypass vessels from the left external iliac artery to the right femoral artery under the skin of the lower abdomen. Two of the three bypasses were occluded. In the blood flow to the intestinal tract, the inferior mesenteric artery was already occluded. Peripheral blood flow in the common iliac artery depended on blood flow from the artificial blood vessel, and blood flow from the internal iliac artery to the rectum was poor. Blood flow in the anal intestinal tract after excision seemed to be poor, and anastomosis was judged to be at a high risk of leakage. We have a policy of using laparoscopic Hartmann’s surgery. Port and stoma sites were decided by heeding the position of the artificial blood vessels. The port sites on the left were located more inside than usual. First, the stomach was resected, and the stump was evaluated pathologically. There was no tumor residue on the stump. Next, the sigmoid colon was resected before reconstruction . And then stomach reconstruction was performed by Roux-en-Y reconstruction. The jejunum was lifted anterior transverse colon pathway. Finally, the stoma was made in the lower left abdomen. The operation time was 11 h and 24 min. The blood loss volume was 74 ml. Postoperatively, fever was observed at 9 days after the operation, and CT showed pancreatic fistula (grade B). The patient improved with antibiotics. He was discharged at 21 days after the operation. The pathological diagnosis showed that there was another lesion in the stomach. It was unknown before the operation. In the end, there were three lesions. One was a submucosal invasion, and the others were intramucosal cancers. All were Stage I. Sigmoid colon cancer was T3N0M0 Stage II A. Two years have passed since the operation and there has been no recurrence.", + "fulltext_subclaims": [ + "The patient was a 69-year-old man.", + "He was hospitalized with transient loss of consciousness due to severe anemia and melena.", + "He had previously suffered from thromboangitis obliterans.", + "He had undergone revascularization of his lower extremities.", + "Upper gastrointestinal endoscopy showed two lesions.", + "One 15 mm-sized depressed lesion was present in the lesser curvature of the cardia.", + "Biopsy diagnosed poor differentiated tubular adenocarcinoma.", + "Endoscopic ultrasound showed the tumor had invaded the submucosa.", + "Surgery was necessary.", + "The other lesion was present on the posterior wall of the body in the stomach.", + "A biopsy of this ulcer scar was diagnosed as suspected gastric cancer.", + "Lower gastrointestinal endoscopy revealed a circumferential type 2 tumor in the sigmoid colon.", + "The tumor was 38 cm from the anal verge.", + "Biopsy revealed moderately differentiated tubular adenocarcinoma.", + "The lumen was narrowed by this tumor, but the scope managed to pass.", + "Preoperative CT showed no swollen lymph nodes around the gastric lesions.", + "The sigmoid colon had thickened walls and increased concentration of surrounding adipose tissue.", + "There were no swollen lymph nodes around the sigmoid colon lesion in preoperative CT.", + "There was no distant metastasis to the gastric cancer or sigmoid colon cancer.", + "Preoperative diagnosis was T1N0M0 Stage I (UICC 8th Edition) for two gastric cancers.", + "Preoperative diagnosis was T4aN0M0 Stage II B (UICC 8th Edition) for sigmoid colon cancer.", + "The lesion in the body of the stomach was an intramucosal lesion.", + "It was singled out for endoscopic treatment.", + "Preoperative treatment was not performed because of a lack of time.", + "The symptoms of sigmoid colon lesions began to appear.", + "The policy was total gastrectomy for removing two gastric cancers.", + "Preoperative CT and blood vessel construction using 3D image analysis software showed artificial blood vessels under the skin.", + "There was a bypass vessel from the left axillary artery to the left femoral artery under the skin on the left side of the thoracoabdominal region.", + "There were three bypass vessels from the left external iliac artery to the right femoral artery under the skin of the lower abdomen.", + "Two of the three bypasses were occluded.", + "The inferior mesenteric artery was already occluded.", + "Peripheral blood flow in the common iliac artery depended on blood flow from the artificial blood vessel.", + "Blood flow from the internal iliac artery to the rectum was poor.", + "Blood flow in the anal intestinal tract after excision seemed to be poor.", + "Anastomosis was judged to be at a high risk of leakage.", + "The policy was to use laparoscopic Hartmann’s surgery.", + "Port and stoma sites were decided by heeding the position of the artificial blood vessels.", + "The port sites on the left were located more inside than usual.", + "The stomach was resected first.", + "The stump was evaluated pathologically.", + "There was no tumor residue on the stump.", + "Next, the sigmoid colon was resected before reconstruction.", + "Stomach reconstruction was performed by Roux-en-Y reconstruction.", + "The jejunum was lifted via the anterior transverse colon pathway.", + "The stoma was made in the lower left abdomen.", + "The operation time was 11 h and 24 min.", + "The blood loss volume was 74 ml.", + "Postoperatively, fever was observed at 9 days after the operation.", + "CT showed pancreatic fistula (grade B).", + "The patient improved with antibiotics.", + "He was discharged at 21 days after the operation.", + "The pathological diagnosis showed that there was another lesion in the stomach.", + "It was unknown before the operation.", + "In the end, there were three lesions.", + "One was a submucosal invasion.", + "The others were intramucosal cancers.", + "All were Stage I.", + "Sigmoid colon cancer was T3N0M0 Stage II A.", + "Two years have passed since the operation.", + "There has been no recurrence." + ], + "summary": "A 69-year-old man had early gastric cancer and advanced sigmoid colon cancer. He had suffered from thromboangitis obliterans and has undergone revascularization many times due to poor blood flow in his lower limbs. He had had some artificial blood vessels inserted under the skin, confirmed by blood vessel construction image by preoperative computed tomography (CT). There was a bypass vessel from the left axillary artery to the left femoral artery under the skin of the left thoracoabdominal. In addition, there were two bypass vessels from the left external iliac artery to the right femoral artery under the skin of the lower abdomen. One of the two bypasses was occluded. In the blood flow to the intestinal tract, the inferior mesenteric artery was already occluded. Peripheral blood flow in the common iliac artery depended on blood flow from the artificial blood vessel, and blood flow from the internal iliac artery to the rectum was poor. Laparoscopic Hartmann's operation was performed for Stage II B (UICC 8th Edition) sigmoid colon cancer. Because the blood flow in the intestinal tract on the anal side was poor, we thought that anastomosis was at a high risk for leakage. Laparoscopic total gastrectomy was also performed simultaneously for two Stage I (UICC 8th edition) gastric cancers in the cardia and body. The location of the port site and stoma was carefully determined preoperatively to prevent damage and infection to the artificial blood vessels. Minimal invasive surgery was performed using laparoscopic surgery.", + "summary_subclaims": [ + "The patient is a 69-year-old man.", + "He had early gastric cancer.", + "He had advanced sigmoid colon cancer.", + "He had suffered from thromboangitis obliterans.", + "He has undergone revascularization many times due to poor blood flow in his lower limbs.", + "He had had some artificial blood vessels inserted under the skin.", + "The presence of artificial blood vessels was confirmed by preoperative computed tomography.", + "There was a bypass vessel from the left axillary artery to the left femoral artery under the skin of the left thoracoabdominal.", + "There were two bypass vessels from the left external iliac artery to the right femoral artery under the skin of the lower abdomen.", + "One of the two bypasses was occluded.", + "The inferior mesenteric artery was already occluded.", + "Peripheral blood flow in the common iliac artery depended on blood flow from the artificial blood vessel.", + "Blood flow from the internal iliac artery to the rectum was poor.", + "Laparoscopic Hartmann's operation was performed for Stage II B (UICC 8th Edition) sigmoid colon cancer.", + "Anastomosis was thought to be at a high risk for leakage.", + "Laparoscopic total gastrectomy was performed simultaneously for two Stage I (UICC 8th edition) gastric cancers in the cardia and body.", + "The location of the port site and stoma was carefully determined preoperatively.", + "The port site and stoma location was determined to prevent damage and infection to the artificial blood vessels.", + "Minimal invasive surgery was performed using laparoscopic surgery." + ] + }, + { + "id": "multiclinsum_test_1606_en.txt", + "fulltext": "A 7.6-year-old boy was referred for investigation of short stature. He was born after 39 weeks of gestation, with a birth weight of 3.38 kg (0.0 SD) and birth length of 47 cm (− 1.8 SD). Since the age of 1 year, height SD had gradually decreased from − 1.7 to − 3.3 SD, whereas the mid-parental height was − 0.8 SD. He did not have polydipsia or polyuria. The boy had previously been diagnosed with an autistic spectrum disorder, but his clinical examination was otherwise unremarkable; he had normal genitalia and there were no signs of puberty (Tanner stages A1 P1 G1, testes 1/1 ml). There was no familial history of constitutional delay. Endocrine results were suggestive of partial GH deficiency (circulating insulin-like growth factor-I 48 μg/L (− 2.5 SD) ; peak GH of 8.9 μg/L after glucagon). TSH was borderline elevated but free T4 was normal (TSH 5.3 mIU/L, free T4 14.6 pmol/L), and basal concentrations of circulating cortisol (8.8 μg/dL), dehydroepiandrosterone-sulphate (DHEAS 0.6785 μmol/L), luteinizing hormone (LH < 0.1 IU/L), follicle stimulating hormone (FSH 0.8 IU/L) and prolactin (4.7 μg/L) were unremarkable. MRI of the brain revealed a lipoma on the midline adjacent to the hypothalamus . The appearance of the anterior and posterior pituitary gland was normal. GH replacement treatment significantly increased height velocity from 5.2 cm/year to 9.4 cm/year in the first year of catch-up growth .", + "fulltext_subclaims": [ + "The patient is a 7.6-year-old boy.", + "He was referred for investigation of short stature.", + "He was born after 39 weeks of gestation.", + "His birth weight was 3.38 kg (0.0 SD).", + "His birth length was 47 cm (− 1.8 SD).", + "Since the age of 1 year, height SD had gradually decreased from − 1.7 to − 3.3 SD.", + "The mid-parental height was − 0.8 SD.", + "He did not have polydipsia.", + "He did not have polyuria.", + "He had previously been diagnosed with an autistic spectrum disorder.", + "His clinical examination was otherwise unremarkable.", + "He had normal genitalia.", + "There were no signs of puberty (Tanner stages A1 P1 G1, testes 1/1 ml).", + "There was no familial history of constitutional delay.", + "Endocrine results were suggestive of partial GH deficiency.", + "Circulating insulin-like growth factor-I was 48 μg/L (− 2.5 SD).", + "Peak GH after glucagon was 8.9 μg/L.", + "TSH was 5.3 mIU/L.", + "Free T4 was 14.6 pmol/L.", + "Basal concentrations of circulating cortisol were 8.8 μg/dL.", + "Basal concentrations of dehydroepiandrosterone-sulphate were 0.6785 μmol/L.", + "Basal concentrations of luteinizing hormone were < 0.1 IU/L.", + "Basal concentrations of follicle stimulating hormone were 0.8 IU/L.", + "Basal concentrations of prolactin were 4.7 μg/L.", + "MRI of the brain revealed a lipoma on the midline adjacent to the hypothalamus.", + "The appearance of the anterior and posterior pituitary gland was normal.", + "GH replacement treatment significantly increased height velocity from 5.2 cm/year to 9.4 cm/year in the first year of catch-up growth." + ], + "summary": "A 7-year-old boy was referred for short stature and proved to be partially growth-hormone deficient. Magnetic resonance imaging (MRI) revealed a lipoma in the paramedian hypothalamus. Growth hormone treatment resulted in swift and uncomplicated catch-up growth.", + "summary_subclaims": [ + "A 7-year-old boy was referred for short stature.", + "He was proved to be partially growth-hormone deficient.", + "MRI revealed a lipoma in the paramedian hypothalamus.", + "Growth hormone treatment resulted in swift and uncomplicated catch-up growth." + ] + }, + { + "id": "multiclinsum_test_934_en.txt", + "fulltext": "A 39-year-old woman contacted the ambulance service stating that she was choking. On assessment by the attending paramedic, she was sat upright on the sofa, appeared systemically well but was distressed. She had a patent airway, although her uvula was deviated to the left. She had a hoarse voice and was unable to talk properly. She confirmed that she had a sensation of choking, but had good bilateral air entry on examination with no additional sounds. Her physiological observations were all normal and a 3-lead electrocardiogram showed a sinus rhythm of 70 beats per minute.\nOn further assessment, an implanted device under the patient’s left clavicle was discovered, which turned out to be a VNS. As the patient’s condition spontaneously improved, she explained that she had experienced a ‘tingling’ sensation in her throat. She had interpreted this as the onset of a seizure, so had swiped her ring magnet to activate the VNS. However, the ‘tingling’ sensation had become worse, leading to a cycle of further VNS activations with the magnet and worsening of symptoms until she was unable to speak and felt as though she was choking.\nThe paramedic provided reassurance and advice, and on learning that the patient did not feel confident about using her device, advised her to contact her specialist neurology team the next day for follow-up and further advice. Now understanding that the choking sensation was a common side effect and nothing to worry about, the patient was content with the management plan. The patient was not transported to hospital, so the treating paramedic added that she or anyone around her should still call for help if she had a seizure leading to injury, a seizure lasting more than five minutes or repeat seizures without recovery in between .", + "fulltext_subclaims": [ + "The patient was a 39-year-old woman.", + "She contacted the ambulance service stating that she was choking.", + "On assessment, she was sat upright on the sofa.", + "She appeared systemically well but was distressed.", + "She had a patent airway.", + "Her uvula was deviated to the left.", + "She had a hoarse voice.", + "She was unable to talk properly.", + "She confirmed that she had a sensation of choking.", + "She had good bilateral air entry on examination.", + "There were no additional sounds on examination.", + "Her physiological observations were all normal.", + "A 3-lead electrocardiogram showed a sinus rhythm of 70 beats per minute.", + "An implanted device under the patient’s left clavicle was discovered.", + "The implanted device turned out to be a VNS.", + "The patient’s condition spontaneously improved.", + "She explained that she had experienced a ‘tingling’ sensation in her throat.", + "She had interpreted the ‘tingling’ sensation as the onset of a seizure.", + "She had swiped her ring magnet to activate the VNS.", + "The ‘tingling’ sensation had become worse.", + "This led to a cycle of further VNS activations with the magnet.", + "This led to worsening of symptoms until she was unable to speak.", + "She felt as though she was choking.", + "The paramedic provided reassurance and advice.", + "The paramedic advised her to contact her specialist neurology team the next day for follow-up and further advice.", + "The patient was not transported to hospital.", + "The treating paramedic added that she or anyone around her should still call for help if she had a seizure leading to injury.", + "The treating paramedic added that she or anyone around her should still call for help if she had a seizure lasting more than five minutes.", + "The treating paramedic added that she or anyone around her should still call for help if she had repeat seizures without recovery in between." + ], + "summary": "This case study discusses the encounter between a paramedic and a woman presenting with a choking sensation, isolated uvular deviation and stable cardiorespiratory functions. Following a short period of observation without adverse events, she was discharged on scene and advised to see her specialist epilepsy nurse.", + "summary_subclaims": [ + "The patient presented with a choking sensation.", + "The patient had isolated uvular deviation.", + "The patient had stable cardiorespiratory functions.", + "The patient was observed for a short period without adverse events.", + "The patient was discharged on scene.", + "The patient was advised to see her specialist epilepsy nurse." + ] + }, + { + "id": "multiclinsum_test_3240_en.txt", + "fulltext": "A 17-year-old patient presented to the emergency department in November 2019 following the sudden onset of low back pain when he stood up. His main medical history included bilateral hearing loss since 2017, chronic gastritis with Helicobacter pylori treated with antibiotics in February 2019, and recent episodes of “red urine”. There was no traumatic background and the pain was inflammatory, without irradiation to the lower limbs. On clinical examination, there was a significant bilateral paravertebral contracture, without pain triggered by palpation of the spinal nerves. The pain was relieved only by analgesics of level 3.\nThe biochemical profile showed a CRP initially at 68 mg/L, increasing to 202 mg/L, with a hyperleucocytosis of neutrophils (14 G/L), as well as an increase in CPK to 66 336 IU/L (N < 192 IU/L). The infectious and autoimmune profiles, including the DOT myositis, were negative. In view of the inflammatory and hyperalgesic nature of the lower back pain, a spinal MRI was performed, showing a myofasciitis necrotizing affecting the erector spinae, iliocostalis lumborum, longissimus thoracis, transverse spinae and quadratus lumborum bilaterally extended in relation to L1 to S3. A biopsy of the paraspinal muscles showed complete myocyte necrosis, associated with a recent infarction, without further specificity. After rest, the patient described a clear improvement in his lower back pain, but the CPK remained elevated, between 1116 and 1752 IU/L, on the control biological tests the following months. The control MRI at 3 months found areas of sequellae necrosis at the level of the erector spinae muscles in particular. When reviewing the patient's history, there were difficulties in playing sports since childhood, in a context of significant muscular fatigue. There was no phenomenon of second breath. The etiological profile was then completed with a non-ischemic forearm stress test that did not find an elevation of lactate acidemia, at 0.70 mmol/L before a stress and a maximum of 1.18 mmol/L after a stress. In view of this result suggestive of GSD 5, a molecular study of the PYGM gene showed the presence of two variants in a heterozygous state: the c.1963G>A (p.Glu655Lys) class 5 variant that has already been described in the literature and whose various prediction tools are in favour of its pathogenicity, and the c.2178-1G>A class 4 variant that has never been described but that affects a consensus splicing site and is very likely pathogenic. These results were in favour of the diagnosis of GSD 5. After three years of follow-up, the patient did not present a new access of lower back pain but remained limited to practising a sport.\n", + "fulltext_subclaims": [ + "The patient is a 17-year-old male.", + "He presented to the emergency department in November 2019.", + "He had sudden onset of low back pain when he stood up.", + "His main medical history included bilateral hearing loss since 2017.", + "He had chronic gastritis with Helicobacter pylori treated with antibiotics in February 2019.", + "He had recent episodes of 'red urine'.", + "There was no traumatic background.", + "The pain was inflammatory.", + "The pain was relieved only by analgesics of level 3.", + "The initial CRP was 68 mg/L.", + "The CRP increased to 202 mg/L.", + "There was a hyperleucocytosis of neutrophils at 14 G/L.", + "The CPK was 66 336 IU/L.", + "The infectious and autoimmune profiles, including the DOT myositis, were negative.", + "A spinal MRI showed a myofasciitis necrotizing affecting the erector spinae, iliocostalis lumborum, longissimus thoracis, transverse spinae, and quadratus lumborum bilaterally.", + "The MRI findings were in relation to L1 to S3.", + "A biopsy of the paraspinal muscles showed complete myocyte necrosis.", + "The biopsy showed a recent infarction.", + "The CPK remained elevated between 1116 and 1752 IU/L on control biological tests the following months.", + "The control MRI at 3 months found areas of sequellae necrosis at the level of the erector spinae muscles.", + "The patient described a clear improvement in his lower back pain after rest.", + "There were difficulties in playing sports since childhood.", + "There was no phenomenon of second breath.", + "A non-ischemic forearm stress test did not find an elevation of lactate acidemia.", + "The lactate acidemia was 0.70 mmol/L before stress and a maximum of 1.18 mmol/L after stress.", + "The results were suggestive of GSD 5.", + "A molecular study of the PYGM gene showed the presence of two variants in a heterozygous state.", + "The c.1963G>A (p.Glu655Lys) variant is class 5 and has already been described in the literature.", + "The c.2178-1G>A variant is class 4 and has never been described.", + "The c.2178-1G>A variant affects a consensus splicing site and is very likely pathogenic.", + "These results were in favour of the diagnosis of GSD 5.", + "After three years of follow-up, the patient did not present a new access of lower back pain.", + "The patient remained limited to practising a sport." + ], + "summary": "We report the case of a 17-year-old patient who presented to the emergency department with acute inflammatory low back pain with no history of trauma, with a CPK elevation of greater than 66,000 IU/L (N < 192 IU/L) and a CRP of 202 mg/L. The immunological profile was negative and the spinal MRI showed a myofasciitis-like appearance with necrosis of the erector spinae muscles. Given the history of difficulty in physical activity since childhood and a non-ischemic arm exercise test that did not show an increase in lactate dehydrogenase, the diagnosis was oriented toward GSD 5. Molecular analysis of the PYGM gene (NM_005609.4) identified two heterozygous variants: c.1963G>A (p.Glu655Lys) of class 5 and c.2178-1G>A of class 4, confirming the diagnosis of McArdle's disease.\n", + "summary_subclaims": [ + "The patient was a 17-year-old.", + "The patient presented with acute inflammatory low back pain.", + "The patient had no history of trauma.", + "The CPK was greater than 66,000 IU/L.", + "The CRP was 202 mg/L.", + "The immunological profile was negative.", + "The spinal MRI showed a myofasciitis-like appearance.", + "The MRI showed necrosis of the erector spinae muscles.", + "The patient had difficulty in physical activity since childhood.", + "The arm exercise test was non-ischemic.", + "The arm exercise test did not show an increase in lactate dehydrogenase.", + "The diagnosis was oriented toward GSD 5.", + "Molecular analysis of the PYGM gene identified two heterozygous variants.", + "One variant was c.1963G>A (p.Glu655Lys) of class 5.", + "The other variant was c.2178-1G>A of class 4.", + "The diagnosis of McArdle's disease was confirmed." + ] + }, + { + "id": "multiclinsum_test_574_en.txt", + "fulltext": "A 68-year-old male presented with entire body burns. He tried to commit suicide by burning himself on the riverbed, and covered his head with 10-liters of gasoline and set himself on fire. He had a history of insomnia and anxiety. He had no history of allergic responses and no smoking history. Vital signs on admission were as follows; Glasgow Coma Scale 15 points, body temperature 35.8°C, heart rate 98 bpm, blood pressure 170/85 mm Hg, respiratory rate 20 bpm, and oxygen saturation 100% with 10-liter mask. Erythema and bullae were observed on the auricular to mandible neck, thorax, abdomen, occiput, right upper arm, right dorsal hand, and left forearm. His anterior chest and posterior neck were covered with soot, and the skin in these areas had turned a grayish white . Soot was observed in the nasal and oral cavity, pharynx, and larynx, suggesting burn of the upper respiratory tract. Bronchoscopy showed soot adhesion, peripheral edema, and mucosal redness from the vocal cords to the period. Total burn surface area was 35%, which included 20% second-degree burns and 15% third-degree burns. The revised BAUX score was 120.\nAn overview of the hospital is shown in Figure . The burn-site was washed daily with warm water, treated with dimethyl isopropylazulene and gentamicin sulfate ointment and protected with moist wound care pads. At the time of admission, the guarantor's approval was not obtained, which prevented aggressive initial burn treatment such as debridement and skin grafting.\nOn day 8, he had a high fever of 38°C–40°C with a markedly increased inflammatory response, and the blood culture revealed methicillin-resistant Staphylococcus aureus. Vancomycin and ampicillin/sulbactam were administered empirically against the burn-site infections. After the infections were under the control, the first split-thickness skin grafts (STSG) were performed on day 17 in the operating room. The skin grafts (0.01 inch graft) were harvested from the healthy skin on both thighs by using electric dermatome and meshed for expansion at the ratio of 1:3. After the first debridement and STSG on day 17, ampicillin/sulbactam was discontinued because of the appearance of erythema mainly on the lateral abdomen and suspected drug rash. Cefepime dihydrochloride hydrate was driven to start because acinetobacter baumannii was detected from a blood culture on day 20. Because the burn-site infections had been continuously manageable, the second STSG for the back area was performed on day 24. The skin was harvested from both lateral thighs and meshed at a ratio of 1:1.5.\nFrom day 30, the redness on the trunk and extremities rapidly worsened, and some blistering was observed. We diagnosed as erythema multiforme because of drug eruption, then all antimicrobial agents were terminated. Because the erythema multiforme did not improve after the discontinuation of antimicrobial therapy, systemic administration of 40 mg/day prednisolone was initiated. However, on day 35, the erythema expanded and erosions and blisters formed on more than 30% of the body surface area. Nikolsky phenomenon and oral mucosal lesions were observed, especially on the back and extremities . Because erythema, blisters, and erosions were widely distributed and exceeded 10% of the body surface area with a fever above 38°C, we diagnosed the case as TEN and initiated steroid-pulse therapy (methylprednisolone 1,000 mg/day) for 3 days. This treatment was successful and the erosions and blisters gradually improved without any exacerbation of infection. On day 37, the erythema began to fade . On day 38, we switched the steroids therapy to oral prednisolone 60 mg/day. Prednisolone was tapered by 10 mg every week. No signs of infection was observed after discontinuation of antimicrobial therapy and steroid pulse therapy, and he discharged from ICU on day 41.\nThereafter, an additional debridement for the anterior thoracic region on day 59, STSG for anterior neck, shoulder, and thoracic (from lower abdomen skin) on day 73, and STSG for lateral neck (from posterior aspect of both thighs) on day 87 were performed under general anesthesia . After debridement and skin grafting for a total of five times, he was transferred to a general hospital on day 140. Lymphocyte stimulation test of the antibiotics used was performed to search for the cause of TEN, but it could not be identified.", + "fulltext_subclaims": [ + "The patient is a 68-year-old male.", + "He presented with entire body burns.", + "He tried to commit suicide by burning himself on the riverbed.", + "He covered his head with 10-liters of gasoline and set himself on fire.", + "He had a history of insomnia.", + "He had a history of anxiety.", + "He had no history of allergic responses.", + "He had no smoking history.", + "On admission, Glasgow Coma Scale was 15 points.", + "On admission, body temperature was 35.8°C.", + "On admission, heart rate was 98 bpm.", + "On admission, blood pressure was 170/85 mm Hg.", + "On admission, respiratory rate was 20 bpm.", + "On admission, oxygen saturation was 100% with 10-liter mask.", + "Erythema and bullae were observed on the auricular to mandible neck.", + "Erythema and bullae were observed on the thorax.", + "Erythema and bullae were observed on the abdomen.", + "Erythema and bullae were observed on the occiput.", + "Erythema and bullae were observed on the right upper arm.", + "Erythema and bullae were observed on the right dorsal hand.", + "Erythema and bullae were observed on the left forearm.", + "The anterior chest and posterior neck were covered with soot.", + "The skin in the anterior chest and posterior neck had turned a grayish white.", + "Soot was observed in the nasal and oral cavity.", + "Soot was observed in the pharynx.", + "Soot was observed in the larynx.", + "Soot adhesion was observed from the vocal cords to the period.", + "Peripheral edema was observed from the vocal cords to the period.", + "Mucosal redness was observed from the vocal cords to the period.", + "Total burn surface area was 35%.", + "The burn included 20% second-degree burns.", + "The burn included 15% third-degree burns.", + "The revised BAUX score was 120.", + "The burn-site was washed daily with warm water.", + "The burn-site was treated with dimethyl isopropylazulene and gentamicin sulfate ointment.", + "The burn-site was protected with moist wound care pads.", + "At the time of admission, the guarantor's approval was not obtained.", + "Aggressive initial burn treatment such as debridement and skin grafting was prevented.", + "On day 8, he had a high fever of 38°C–40°C.", + "On day 8, blood culture revealed methicillin-resistant Staphylococcus aureus.", + "Vancomycin was administered empirically against the burn-site infections.", + "Ampicillin/sulbactam was administered empirically against the burn-site infections.", + "The first split-thickness skin grafts were performed on day 17.", + "The skin grafts were harvested from the healthy skin on both thighs.", + "The skin grafts were meshed at a ratio of 1:3.", + "Ampicillin/sulbactam was discontinued because of the appearance of erythema mainly on the lateral abdomen.", + "Cefepime dihydrochloride hydrate was started because acinetobacter baumannii was detected from a blood culture on day 20.", + "The second STSG for the back area was performed on day 24.", + "The skin was harvested from both lateral thighs.", + "The skin was meshed at a ratio of 1:1.5.", + "On day 30, the redness on the trunk and extremities rapidly worsened.", + "Some blistering was observed.", + "Erythema multiforme was diagnosed.", + "All antimicrobial agents were terminated.", + "Systemic administration of 40 mg/day prednisolone was initiated.", + "On day 35, the erythema expanded.", + "Erosions and blisters formed on more than 30% of the body surface area.", + "Nikolsky phenomenon was observed.", + "Oral mucosal lesions were observed.", + "The case was diagnosed as TEN.", + "Steroid-pulse therapy (methylprednisolone 1,000 mg/day) was initiated for 3 days.", + "The treatment was successful.", + "The erosions and blisters gradually improved.", + "On day 37, the erythema began to fade.", + "On day 38, steroids therapy was switched to oral prednisolone 60 mg/day.", + "Prednisolone was tapered by 10 mg every week.", + "No signs of infection were observed after discontinuation of antimicrobial therapy.", + "He was discharged from ICU on day 41.", + "An additional debridement for the anterior thoracic region was performed on day 59.", + "STSG for anterior neck, shoulder, and thoracic was performed on day 73.", + "STSG for lateral neck was performed on day 87.", + "After debridement and skin grafting for a total of five times, he was transferred to a general hospital on day 140.", + "Lymphocyte stimulation test of the antibiotics used was performed.", + "The cause of TEN could not be identified." + ], + "summary": "A 68-year-old man was carried to our hospital with severe burns covering 35% of his body surface area. He developed bacteremia during treatment of burns and required antimicrobial therapy. However, erythema appeared on the trunk and upper limbs and rapidly spread to the extremities, leading to a diagnosis of TEN. The rash gradually improved after terminating antimicrobial therapy and administrating of 1,000 mg/day methylprednisolone for 3 days. The rash caused by TEN was confined to non-burned areas, suggesting that TEN may less likely occur at burn sites.", + "summary_subclaims": [ + "A 68-year-old man was carried to our hospital with severe burns covering 35% of his body surface area.", + "He developed bacteremia during treatment of burns and required antimicrobial therapy.", + "Erythema appeared on the trunk and upper limbs and rapidly spread to the extremities.", + "The rash gradually improved after terminating antimicrobial therapy.", + "The rash gradually improved after administrating of 1,000 mg/day methylprednisolone for 3 days.", + "The rash caused by TEN was confined to non-burned areas.", + "The rash caused by TEN was confined to non-burned areas, suggesting that TEN may less likely occur at burn sites." + ] + }, + { + "id": "multiclinsum_test_826_en.txt", + "fulltext": "A 60-year-old Thai woman presented with a 4-month history of episodic, painful, horizontal binocular diplopia. She denied any oscillopsia. She was previously treated for nasopharyngeal carcinoma with several courses of chemotherapy and external beam radiotherapy (total dose of 7000 cGy). The tumor was well controlled; her most recent radiotherapy was administered 13 years previously. General neurological examination findings were unremarkable. Neuro-ophthalmic examination revealed normal visual acuity, visual fields, pupils, and fundi. Ocular alignment showed orthotropia and orthophoria by alternate cover test. Her ocular motility was normal in all gazes, including adduction. Myasthenic eyelid signs, including orbicularis oculi weakness, fatigable ptosis, and Cogan’s lid twitch, were absent. However, following a 30-s right eccentric gaze, she developed involuntary contraction of the left medial rectus, which resulted in left esotropia while returning both eyes to the primary position. The left esotropia lasted approximately 2 min, then spontaneously resolved . Likewise, these spells occurred following a 30-s gaze in the opposite direction (left eccentric gaze), which resulted in right esotropia in the primary position . During these spells, esotropia was steady (until it waned) and not variable. Both the pupils and the eyelid positions remained normal throughout the examination. No anisocoria was detected during the episodes of esotropia. Prolonged vertical eccentric gaze did not induce any ocular misalignment. Magnetic resonance imaging revealed neither brain parenchyma/brain stem lesions nor tumor recurrence. Her symptoms were successfully treated with carbamazepine at 200 mg daily.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Thai woman.", + "She had a 4-month history of episodic, painful, horizontal binocular diplopia.", + "She denied any oscillopsia.", + "She was previously treated for nasopharyngeal carcinoma with several courses of chemotherapy and external beam radiotherapy.", + "The total radiotherapy dose was 7000 cGy.", + "The tumor was well controlled.", + "Her most recent radiotherapy was administered 13 years previously.", + "General neurological examination findings were unremarkable.", + "Neuro-ophthalmic examination revealed normal visual acuity.", + "Ocular alignment showed orthotropia and orthophoria by alternate cover test.", + "Ocular motility was normal in all gazes, including adduction.", + "Myasthenic eyelid signs, including orbicularis oculi weakness, fatigable ptosis, and Cogan’s lid twitch, were absent.", + "Following a 30-s right eccentric gaze, she developed involuntary contraction of the left medial rectus.", + "This resulted in left esotropia while returning both eyes to the primary position.", + "The left esotropia lasted approximately 2 min, then spontaneously resolved.", + "Spells occurred following a 30-s left eccentric gaze, which resulted in right esotropia in the primary position.", + "During these spells, esotropia was steady and not variable.", + "Both the pupils and the eyelid positions remained normal throughout the examination.", + "No anisocoria was detected during the episodes of esotropia.", + "Prolonged vertical eccentric gaze did not induce any ocular misalignment.", + "Magnetic resonance imaging revealed neither brain parenchyma/brain stem lesions nor tumor recurrence.", + "Her symptoms were successfully treated with carbamazepine at 200 mg daily." + ], + "summary": "A 60-year-old woman presented with a 4-month history of episodic, painful, horizontal binocular diplopia. She underwent external beam radiotherapy to the skull base for treatment of nasopharyngeal carcinoma. The tumor was well controlled. General neurological examination findings were unremarkable. Neuro-ophthalmic examination revealed normal visual acuity, visual fields, pupils, and fundi. Ocular alignment showed orthotropia with normal ocular motility. Myasthenic eyelid signs were absent. However, she developed episodes of involuntary sustained contraction of the medial rectus muscle following prolonged eccentric gaze toward the affected medial rectus muscle, which resulted in esotropia upon returning to the primary position. The esotropic episodes spontaneously resolved after approximately 2 min. These spells affected both medial rectus muscles. Both pupils remained normal throughout the examination. Magnetic resonance imaging revealed neither brain parenchyma/brain stem lesions nor tumor recurrence. Her symptoms were successfully treated with carbamazepine.", + "summary_subclaims": [ + "The patient is a 60-year-old woman.", + "She had a 4-month history of episodic, painful, horizontal binocular diplopia.", + "She underwent external beam radiotherapy to the skull base for treatment of nasopharyngeal carcinoma.", + "The tumor was well controlled.", + "General neurological examination findings were unremarkable.", + "Neuro-ophthalmic examination revealed normal visual acuity.", + "Neuro-ophthalmic examination revealed normal visual fields.", + "Neuro-ophthalmic examination revealed normal pupils.", + "Neuro-ophthalmic examination revealed normal fundi.", + "Ocular alignment showed orthotropia with normal ocular motility.", + "Myasthenic eyelid signs were absent.", + "She developed episodes of involuntary sustained contraction of the medial rectus muscle following prolonged eccentric gaze toward the affected medial rectus muscle.", + "The esotropia occurred upon returning to the primary position.", + "The esotropic episodes spontaneously resolved after approximately 2 minutes.", + "The spells affected both medial rectus muscles.", + "Both pupils remained normal throughout the examination.", + "Magnetic resonance imaging revealed no brain parenchyma/brain stem lesions.", + "Magnetic resonance imaging revealed no tumor recurrence.", + "Her symptoms were successfully treated with carbamazepine." + ] + }, + { + "id": "multiclinsum_test_1487_en.txt", + "fulltext": "A 91-year-old man hospitalized in our geriatric center for delirium. His medical history consisted of a non-investigated major neurocognitive disorder and peripheral neuropathy of the lower limbs for 4 years with no etiological diagnosis. His usual treatment was ginkgo biloba extract and grape seed extract. He lived at home. His family reported an increase in behavior disturbances associated with cough over the 3 previous weeks.\nAt admission, the physical examination revealed fever, rhinorrhea, cough and widespread bronchi attributed to bronchitis. The neurological examination showed a bilateral loss of epicritic sensitivity in the lower limbs, but normal motor function. Delirium was also noted. There was isolated cervical lymphadenopathy. Initial biological tests showed normal levels of hemoglobin, platelets and leukocytes. A nasopharyngeal swab was taken on admission in order to perform molecular assay for respiratory viruses (i.e., multiplexed in-house RT-PCR for Influenza virus A and B, Rhinovirus/Enterovirus, human Metapneumovirus, Parainfluenza virus, adenovirus, non-SARS-Cov-2 coronavirus) identified a human metapneumovirus (hMPV) infection. Serology for hMPV was not performed.\nThe initial course was favorable with symptomatic care (aerosols of saline solution, paracetamol and respiratory physiotherapy) plus low-dose benzodiazepine for the delirium. Five days after viral diagnosis, the lymphocyte count increased from 1.16 to 10.86 × 109 cells/L, while the symptoms of the infection remained under control. Serum protein electrophoresis suggested inflammation. The immunophenotyping of lymphocytes showed a profile of CD 5+, CD 23+, low FMC-7, and CD19b-, which is consistent with B-chronic lymphocytic leukemia.\nWe did not find other lymphadenopathies, splenomegaly or hepatomegaly during the physical examination or on imagery. He had no B symptoms other than fever consecutive to his infection (i.e., nighttime sweats and weight loss).\nThe lymphocyte count fluctuated considerably during hospitalization, with a maximum of 12.39 × 109/L . We did not perform FISH or IGHV mutation testing.\nBecause of the novel hematological finding and the unclear history of peripheral neuropathy, other laboratory tests, including for cryoglobulins, were performed. Renal and hepatic function were normal. The lab results found monoclonal IgG K cryoglobulinemia (0.1 g/L) associated with an increase in the activity of rheumatoid factor (7.5 IU/mL; normal < 3.5) and C3 (1.756 g/L; normal 0.811–1.570). There was a decrease in C4 activity (0.017 g/L; normal 0.129–0.392). Hepatitis C serology was negative, as were antinuclear antibodies.\nThe diagnosis of CLL associated with type-1 IgG K cryoglobulinemia revealed by hMPV infection was retained. The peripheral neuropathy was linked to an isolated clinical manifestation of cryoglobulinemia.\nGiven the absence of disability, significant gait disorders or skin lesions, the advanced neurocognitive condition, a Binet A (or Rai stage 1) CLL classification and the patient’s age, the care team decided not to treat the CLL. After discharge from the hospital, the patient was admitted to a nursing home.", + "fulltext_subclaims": [ + "A 91-year-old man was hospitalized in a geriatric center for delirium.", + "His medical history included a non-investigated major neurocognitive disorder.", + "He had peripheral neuropathy of the lower limbs for 4 years with no etiological diagnosis.", + "His usual treatment was ginkgo biloba extract and grape seed extract.", + "The family reported an increase in behavior disturbances associated with cough over the 3 previous weeks.", + "At admission, the physical examination revealed fever, rhinorrhea, cough, and widespread bronchi attributed to bronchitis.", + "The neurological examination showed a bilateral loss of epicritic sensitivity in the lower limbs.", + "Delirium was noted.", + "There was isolated cervical lymphadenopathy.", + "A nasopharyngeal swab was taken on admission.", + "A molecular assay for respiratory viruses identified a human metapneumovirus (hMPV) infection.", + "Serology for hMPV was not performed.", + "The initial course was favorable with symptomatic care.", + "Low-dose benzodiazepine was used for the delirium.", + "Five days after viral diagnosis, the lymphocyte count increased from 1.16 to 10.86 × 109 cells/L.", + "Serum protein electrophoresis suggested inflammation.", + "The immunophenotyping of lymphocytes showed a profile of CD 5+, CD 23+, low FMC-7, and CD19b-.", + "This profile is consistent with B-chronic lymphocytic leukemia.", + "No other lymphadenopathies, splenomegaly, or hepatomegaly were found.", + "He had no B symptoms other than fever consecutive to his infection.", + "The lymphocyte count fluctuated considerably during hospitalization, with a maximum of 12.39 × 109/L.", + "FISH or IGHV mutation testing was not performed.", + "The lab results found monoclonal IgG K cryoglobulinemia (0.1 g/L).", + "There was an increase in the activity of rheumatoid factor (7.5 IU/mL).", + "C3 activity was 1.756 g/L.", + "C4 activity was 0.017 g/L.", + "Hepatitis C serology was negative.", + "Antinuclear antibodies were negative.", + "The diagnosis of CLL associated with type-1 IgG K cryoglobulinemia revealed by hMPV infection was retained.", + "The peripheral neuropathy was linked to an isolated clinical manifestation of cryoglobulinemia.", + "The care team decided not to treat the CLL.", + "The patient was admitted to a nursing home after discharge from the hospital." + ], + "summary": "A 91-year-old man was initially hospitalized for delirium. In a context of febrile rhinorrhea, the diagnosis of hMPV infection was made by molecular assay (RT-PCR) on nasopharyngeal swab. Owing to hyperlymphocytosis that developed during the course of the infection and unexplained peripheral neuropathy, a type-1 IgG Kappa CG secondary to a CLL was diagnosed. The patient was not treated for the CLL because of Binet A stage classification and his poor physical condition.", + "summary_subclaims": [ + "A 91-year-old man was initially hospitalized for delirium.", + "The diagnosis of hMPV infection was made by molecular assay (RT-PCR) on nasopharyngeal swab.", + "The patient developed hyperlymphocytosis during the course of the infection.", + "The patient had unexplained peripheral neuropathy.", + "A type-1 IgG Kappa CG secondary to a CLL was diagnosed.", + "The patient was not treated for the CLL.", + "The patient's CLL was classified as Binet A stage.", + "The patient had poor physical condition." + ] + }, + { + "id": "multiclinsum_test_2979_en.txt", + "fulltext": "A previously healthy 13-year-old African American female (body mass index 19.2 kg/m2, 55.99% for age and sex percentile) presented to the emergency department with a chief complaint of altered mental status and difficulty breathing. Symptoms were preceded by 1 day of headache and fever, prompting evaluation at an urgent care center where she was found to be SARS-CoV-2 positive. On the morning of presentation, she sought further evaluation in the emergency department for symptom progression to chest pain, heavy breathing, and confusion. Pertinent examination findings at presentation included disorientation, combative behavior without focal neurologic deficit, tachycardia, Kussmaul breathing, dry mucus membranes, and diffuse abdominal tenderness. Laboratory findings revealed leukocytosis (white blood cell count 22.3 × 103/mcL), anion-gap metabolic acidosis (pH 6.92, pCO2 < 5 torr, base deficit 28), and hyperglycemia (glucose 668 mg/dL). Urinalysis was significant for ketonuria and glucosuria. Physical examination and laboratory findings were consistent with newly diagnosed diabetes mellitus (hemoglobin A1C > 16%) complicated by diabetic ketoacidosis (DKA), likely triggered by acute COVID-19 infection, with features concerning for cerebral edema. She was started on continuous insulin infusion (0.1 units/kg/h), given a bolus of 3% hypertonic saline (HTS), and was admitted to the pediatric intensive care unit (PICU) for further management. DKA was treated according to the institutional protocol with intravenous fluids, continuous insulin infusion, and close electrolyte monitoring.\nDue to persistent alteration in mental status shortly after admission, she received two additional HTS boluses and had head computed tomography (CT) scan, which was normal. Despite these interventions and resolution of metabolic derangements, her mentation remained altered. On day 2 of admission, a brain magnetic resonance imaging (MRI) scan showed abnormal enhancement within the frontal lobe extending from the olfactory floor upward. Additional findings were notable for dehiscence of the planum sphenoidale and involvement of the left nasal cavity near superior turbinate, which was concerning for an infectious cerebritis with possible developing phlegmon/intracranial abscess. In the clinical setting of DKA, these findings were concerning for invasive sinusitis with intracranial extension. Lumbar puncture (LP) was subsequently performed on day 2 and revealed cerebrospinal fluid (CSF) pleocytosis with neutrophilic predominance and negative meningitis encephalitis panel. CSF cultures were not obtained at that time due to limited sample volume. An infectious diseases specialist was consulted and recommended an empiric antimicrobial regimen with ceftriaxone, metronidazole, and liposomal amphotericin B given the risk for invasive fungal disease. The patient did not meet criteria for treatment of acute COVID-19 infection, so steroids and antivirals were deferred.\nOn day 3 of admission, sinus CT scan revealed mild opacification of the superior maeti, maxillary ostium, medial and posterior ethmoid air cells with erosive change of the osseous septa and possible bone defect. An otorhinolaryngology (ENT) surgeon performed an endoscopic nasal examination, notable for friable tissue without evidence of necrosis. Due to limited patient tolerance during the awake examination, biopsies were not obtained at that time. On day 4 of admission, repeat head CT showed interval progression of intracranial pathology with mass effect and cerebral edema suggestive of infectious cerebritis. Repeat LP was unsuccessful, so blood metagenomics testing (Karius test, Redwood City, CA) was obtained on day 5 to aid in the diagnosis. She continued to have daily fevers despite broad-spectrum antimicrobial coverage. Blood cultures obtained at initial presentation remained negative, and an evaluation for endocarditis as a potential source of fever was unrevealing. Invasive fungal disease was most concerning among the differential diagnoses, so posaconazole was added to the antimicrobial regimen on day 7 of admission while awaiting results of the Karius test. Results returned on day 9 of admission and revealed genetic material belonging to the fungal organism Rhizopus delemar. The positive Karius test in the setting of progressive intracranial disease confirmed the diagnosis of rhinocerebral mucormycosis.\nVancomycin, ceftriaxone, and metronidazole were discontinued, and treatment with liposomal amphotericin B and posaconazole was continued at that time. Repeat imaging on day 10 showed disease progression with worsening midline shift while on maximal antifungal therapy, prompting the decision to pursue emergent surgical debridement. The patient underwent frontal craniotomy with drainage of fungal abscess and sphenoidotomy with debridement. Intraoperative findings were notable for invasive fungal infection and necrotizing cerebritis . Pathology revealed necrosis with non-septate broad hyphae and scattered giant cells with micro-abscess formation, and tissue culture isolated Rhizopus species . Posaconazole was discontinued on day 13 due to prolonged QTc interval identified on surveillance electrocardiogram (EKG) and was replaced with isavuconazole. Nasal amphotericin irrigations were performed by ENT as adjunctive therapy.\nThe patient suffered from central diabetes insipidus and neurological deficits including left-sided hemiparesis and persistent fluctuations in mental status. Weekly head imaging was performed for disease surveillance and showed progression of disease despite maximal antifungal therapy. On postoperative day 6 (day 16 of admission), brain MRI showed extension of intracranial infection to the contralateral hemisphere and brainstem involvement. Given these findings, no further neurosurgical intervention was recommended. Progression of the disease continued, and subsequent imaging showed worsening midline shift (1.5 cm on postoperative day 15) with evidence of early temporal lobe herniation. Hospital course was additionally complicated by amphotericin nephrotoxicity, aspiration pneumonia, and venous catheter-associated thrombus formation requiring anticoagulation therapy. Nasal amphotericin irrigations were discontinued on hospital day 20 due to severe nosebleeds during the procedure.\nSupportive care was offered for the aforementioned complications, and the patient continued maintenance therapy with liposomal amphotericin B and isavuconazole. Dose adjustments were made to the antifungals due to renal impairment. Despite these challenges, her clinical status steadily improved. She was transferred to an inpatient rehabilitation facility on hospital day 79 for ongoing medical management and intensive therapies to maximize functional status. After 104 days total of inpatient management, the patient was discharged home and transitioned to outpatient care. Amphotericin B was discontinued at time of discharge, and she remains on isavuconazole monotherapy. As of 10 months from initial diagnosis, she continues showing improvement in functional domains as she can fully ambulate and perform activities of daily living with minimal assistance.", + "fulltext_subclaims": [ + "The patient was a 13-year-old African American female.", + "The patient had a body mass index of 19.2 kg/m2.", + "The patient was at the 55.99% percentile for age and sex.", + "The patient presented with altered mental status.", + "The patient had difficulty breathing.", + "The patient had a 1-day history of headache.", + "The patient had a 1-day history of fever.", + "The patient was found to be SARS-CoV-2 positive at an urgent care center.", + "The patient sought further evaluation in the emergency department.", + "The patient had chest pain on the morning of presentation.", + "The patient had heavy breathing on the morning of presentation.", + "The patient had confusion on the morning of presentation.", + "The patient was disoriented at presentation.", + "The patient had combative behavior at presentation.", + "The patient had tachycardia at presentation.", + "The patient had Kussmaul breathing at presentation.", + "The patient had dry mucus membranes at presentation.", + "The patient had diffuse abdominal tenderness at presentation.", + "The patient had leukocytosis with a white blood cell count of 22.3 × 103/mcL.", + "The patient had an anion-gap metabolic acidosis with a pH of 6.92.", + "The patient had a base deficit of 28.", + "The patient had hyperglycemia with a glucose level of 668 mg/dL.", + "Urinalysis showed ketonuria.", + "Urinalysis showed glucosuria.", + "The patient had newly diagnosed diabetes mellitus.", + "The patient had a hemoglobin A1C greater than 16%.", + "The patient had diabetic ketoacidosis.", + "The patient's DKA was likely triggered by acute COVID-19 infection.", + "The patient had features concerning for cerebral edema.", + "The patient was started on continuous insulin infusion at 0.1 units/kg/h.", + "The patient received a bolus of 3% hypertonic saline.", + "The patient was admitted to the pediatric intensive care unit.", + "The patient received two additional hypertonic saline boluses.", + "A head CT scan was performed.", + "The head CT scan was normal.", + "A brain MRI showed abnormal enhancement within the frontal lobe.", + "The MRI showed extension from the olfactory floor upward.", + "The MRI showed dehiscence of the planum sphenoidale.", + "The MRI showed involvement of the left nasal cavity near the superior turbinate.", + "The findings were concerning for infectious cerebritis.", + "The findings were concerning for possible developing phlegmon/intracranial abscess.", + "The clinical setting was DKA.", + "The findings were concerning for invasive sinusitis with intracranial extension.", + "A lumbar puncture was performed.", + "CSF showed pleocytosis with neutrophilic predominance.", + "The meningitis encephalitis panel was negative.", + "CSF cultures were not obtained due to limited sample volume.", + "An infectious diseases specialist was consulted.", + "The infectious diseases specialist recommended empiric antimicrobial therapy.", + "The patient received ceftriaxone.", + "The patient received metronidazole.", + "The patient received liposomal amphotericin B.", + "The patient did not meet criteria for treatment of acute COVID-19 infection.", + "Steroids were deferred.", + "Antivirals were deferred.", + "A sinus CT scan showed mild opacification of the superior meati.", + "A sinus CT scan showed mild opacification of the maxillary ostium.", + "A sinus CT scan showed mild opacification of the medial and posterior ethmoid air cells.", + "The sinus CT showed erosive change of the osseous septa.", + "The sinus CT showed possible bone defect.", + "An endoscopic nasal examination was performed.", + "The endoscopic nasal examination showed friable tissue.", + "Biopsies were not obtained during the awake examination.", + "Repeat head CT showed interval progression of intracranial pathology.", + "Repeat head CT showed mass effect.", + "Repeat head CT showed cerebral edema.", + "The findings were suggestive of infectious cerebritis.", + "A repeat lumbar puncture was unsuccessful.", + "Blood metagenomics testing (Karius test) was obtained.", + "The Karius test results returned on day 9.", + "The Karius test revealed genetic material belonging to Rhizopus delemar.", + "The positive Karius test confirmed the diagnosis of rhinocerebral mucormycosis.", + "Vancomycin was discontinued.", + "Ceftriaxone was discontinued.", + "Metronidazole was discontinued.", + "Treatment with liposomal amphotericin B was continued.", + "Treatment with posaconazole was continued.", + "Repeat imaging showed disease progression.", + "Repeat imaging showed worsening midline shift.", + "Emergent surgical debridement was pursued.", + "The patient underwent frontal craniotomy.", + "The patient underwent drainage of fungal abscess.", + "The patient underwent sphenoidotomy.", + "The patient underwent debridement.", + "Intraoperative findings were notable for invasive fungal infection.", + "Intraoperative findings were notable for necrotizing cerebritis.", + "Pathology revealed necrosis with non-septate broad hyphae.", + "Pathology revealed scattered giant cells.", + "Pathology revealed micro-abscess formation.", + "Tissue culture isolated Rhizopus species.", + "Posaconazole was discontinued due to prolonged QTc interval.", + "Posaconazole was replaced with isavuconazole.", + "Nasal amphotericin irrigations were performed.", + "The patient had central diabetes insipidus.", + "The patient had left-sided hemiparesis.", + "The patient had persistent fluctuations in mental status.", + "Weekly head imaging showed progression of disease.", + "Brain MRI showed extension to the contralateral hemisphere.", + "Brain MRI showed brainstem involvement.", + "No further neurosurgical intervention was recommended.", + "Subsequent imaging showed worsening midline shift.", + "Subsequent imaging showed evidence of early temporal lobe herniation.", + "The patient had amphotericin nephrotoxicity.", + "The patient had aspiration pneumonia.", + "The patient had venous catheter-associated thrombus.", + "Anticoagulation therapy was initiated.", + "Nasal amphotericin irrigations were discontinued due to severe nosebleeds.", + "The patient was transferred to an inpatient rehabilitation facility.", + "The patient was discharged home after 104 days of inpatient management.", + "Amphotericin B was discontinued at time of discharge.", + "The patient remains on isavuconazole monotherapy.", + "The patient continues showing improvement in functional domains.", + "The patient can fully ambulate.", + "The patient can perform activities of daily living with minimal assistance." + ], + "summary": "We describe the case of a previously healthy 13-year-old African American female patient with newly diagnosed diabetes mellitus and concurrent severe acute respiratory syndrome coronavirus 2 infection whose disease course was complicated by rhinocerebral mucormycosis. She presented with fever, altered mental status, and Kussmaul respirations and was diagnosed with diabetic ketoacidosis with concern for cerebral edema. Concern for infectious cerebritis arose due to recurring fevers and persistently altered mental status despite correction of her metabolic derangements. This raised concern for infectious cerebritis and prompted evaluation with serial head imaging, lumbar puncture, and initiation of broad empiric antimicrobial regimen. Head imaging revealed an evolving cerebral abscess, and fungal deoxyribonucleic acid was identified on blood metagenomics testing, which ultimately confirmed the diagnosis of rhinocerebral mucormycosis. Treatment was challenging as she required surgical debridement of the frontal lobe and aggressive antifungal therapy complicated by electrolyte derangements and electrocardiogram changes that necessitated modification of the antimicrobial regimen. Despite these challenges and high mortality rate, the patient was discharged from the hospital in stable condition to inpatient rehabilitation service for reconditioning after prolonged hospitalization.", + "summary_subclaims": [ + "The patient was a 13-year-old African American female.", + "The patient had newly diagnosed diabetes mellitus.", + "The patient had concurrent severe acute respiratory syndrome coronavirus 2 infection.", + "The patient's disease course was complicated by rhinocerebral mucormycosis.", + "She presented with fever.", + "She presented with altered mental status.", + "She presented with Kussmaul respirations.", + "She was diagnosed with diabetic ketoacidosis.", + "There was concern for cerebral edema.", + "Concern for infectious cerebritis arose due to recurring fevers.", + "Concern for infectious cerebritis arose due to persistently altered mental status.", + "Serial head imaging was performed.", + "Lumbar puncture was performed.", + "A broad empiric antimicrobial regimen was initiated.", + "Head imaging revealed an evolving cerebral abscess.", + "Fungal deoxyribonucleic acid was identified on blood metagenomics testing.", + "The diagnosis of rhinocerebral mucormycosis was confirmed.", + "Treatment required surgical debridement of the frontal lobe.", + "Treatment required aggressive antifungal therapy.", + "Electrolyte derangements complicated the treatment.", + "Electrocardiogram changes necessitated modification of the antimicrobial regimen.", + "The patient was discharged from the hospital in stable condition.", + "The patient was discharged to inpatient rehabilitation service.", + "The patient's hospitalization was prolonged." + ] + }, + { + "id": "multiclinsum_test_43_en.txt", + "fulltext": "A previously healthy 38-year-old Caucasian man and competitive amateur cyclist sustained a displaced fracture of his left femoral neck following a fall from his racing bicycle whilst at rest. Having slowed gradually to a halt, our patient attempted to unclip his feet from the pedals. He was unable to unclip his feet and when the bicycle slipped on some ice, he was unable to remove his feet to steady himself. As a result he sustained a direct trauma to his left hip, resulting in a displaced intra-capsular fracture of the right femoral neck .\nOnce other injuries had been excluded and adequate imaging had been obtained, our patient was admitted to our orthopedic ward and a closed reduction and internal fixation was performed later the same day. Reduction was obtained using the Leadbetter maneuver , and fixation performed with three 6.5 mm cannulated screws . The surgical treatment was completed within 12 hours of the injury. Subsequent to the fixation our patient progressed well with no immediate complications and was discharged two days following the injury. Toe touch weight bearing was commenced for a period of six weeks and, following satisfactory radiographs, partial weight bearing was allowed for a further six weeks.\nAlthough our patient had no risk factors for osteoporosis, given the relatively low energy of the injury, a bone density scan was performed along with other metabolic bone disease screening tests. These were all within normal limits.\nAt a subsequent review four months after the injury, our patient had no pain in the hip, a good range of movement and is walking unaided. Radiographic appearances are satisfactory and show no evidence of avascular necrosis. Regular clinical and radiographic review is planned until two years after the injury.", + "fulltext_subclaims": [ + "The patient is a 38-year-old Caucasian man.", + "The patient is a competitive amateur cyclist.", + "The patient sustained a displaced fracture of his left femoral neck.", + "The fracture resulted from a fall from his racing bicycle.", + "The fall occurred whilst at rest.", + "The patient was unable to unclip his feet from the pedals.", + "The bicycle slipped on some ice.", + "The patient was unable to remove his feet to steady himself.", + "The patient sustained a direct trauma to his left hip.", + "The injury resulted in a displaced intra-capsular fracture of the right femoral neck.", + "The patient was admitted to the orthopedic ward.", + "A closed reduction and internal fixation was performed later the same day.", + "Reduction was obtained using the Leadbetter maneuver.", + "Fixation was performed with three 6.5 mm cannulated screws.", + "The surgical treatment was completed within 12 hours of the injury.", + "The patient progressed well with no immediate complications.", + "The patient was discharged two days following the injury.", + "Toe touch weight bearing was commenced for a period of six weeks.", + "Partial weight bearing was allowed for a further six weeks.", + "The patient had no risk factors for osteoporosis.", + "A bone density scan was performed.", + "Other metabolic bone disease screening tests were performed.", + "The bone density scan and other tests were within normal limits.", + "At a review four months after the injury, the patient had no pain in the hip.", + "Radiographic appearances showed no evidence of avascular necrosis.", + "Regular clinical and radiographic review is planned until two years after the injury." + ], + "summary": "A 38-year-old Caucasian man who was a club cyclist sustained a displaced intracapsular fracture of the hip whilst cycling. As a direct result of the incorrect set-up of his clipless pedals he was unable to release his feet whilst slowing to a halt. This resulted in a loss of balance and subsequent fall with a direct impact onto his left hip. The resulting fracture was managed successfully with early closed reduction and fixation. At six month review he was walking unaided without pain but, as yet, has been unable to return to cycling.", + "summary_subclaims": [ + "The patient is a 38-year-old Caucasian man.", + "He was a club cyclist.", + "He sustained a displaced intracapsular fracture of the hip.", + "The injury occurred whilst cycling.", + "The injury was a direct result of the incorrect set-up of his clipless pedals.", + "He was unable to release his feet whilst slowing to a halt.", + "This resulted in a loss of balance.", + "This resulted in a subsequent fall.", + "The fall had a direct impact onto his left hip.", + "The resulting fracture was managed successfully with early closed reduction and fixation.", + "At six month review he was walking unaided without pain.", + "He has been unable to return to cycling." + ] + }, + { + "id": "multiclinsum_test_267_en.txt", + "fulltext": "Our patient is a 13-year-old Roma girl (ASA physical status III) prepared for T2–L2 posterior scoliosis correction and fusion.\nThe patient suffered from mild mental retardation; however, communication was unhindered. She walked without support for a distance of approximately 20 m, but had limitation in movement of the upper extremities due to peripheral neuropathy. Facial dysmorphism was presented by prominent nasal philtrum and upper incisors.\nThe progressive curve of scoliosis limited the possibility of rehabilitation, therefore brace treatment was not prescribed for our patient. The Cobb angle was 83°.\nPrevious general anesthesia for cataract operation at the University Hospital in Prague was uncomplicated. We could not obtain more information about the course of anesthesia used.\nThe patient was diagnosed with a patent foramen ovale and pulmonary valve stenosis, both hemodynamically insignificant without contraindication to the procedure in the prone position.\nThe patient had no significant family history. Rhabdomyolysis, seizure, or CCFDN syndrome was not present in her family relatives.\nThe patient's body weight was 45 kg and her height was 136 cm; however, the scoliosis curve reduced her actual height. Her Mallampati score was 1. The cardiovascular system was not affected and valve disease was insignificant. Her ASA score was III.\nOn admission, laboratory test results were within normal limits. There was no abnormality in blood count, biochemical tests, or coagulation.\nPulmonary functions were dominantly limited by restrictive lung disease (forced vital capacity, 54%; forced expiratory volume in 1 s, 62%).\nChest X-ray was limited by chest scoliosis and revealed no abnormal lung and heart pathology. Echocardiography found hemodynamically insignificant valve disease. X-ray demonstrated a significant and progressive scoliosis curve with a Cobb angle 83° .", + "fulltext_subclaims": [ + "The patient is a 13-year-old Roma girl.", + "The patient's ASA physical status is III.", + "The patient is prepared for T2–L2 posterior scoliosis correction and fusion.", + "The patient suffered from mild mental retardation.", + "Communication was unhindered.", + "The patient walked without support for a distance of approximately 20 m.", + "The patient had limitation in movement of the upper extremities due to peripheral neuropathy.", + "Facial dysmorphism was presented by prominent nasal philtrum and upper incisors.", + "The progressive curve of scoliosis limited the possibility of rehabilitation.", + "Brace treatment was not prescribed for the patient.", + "The Cobb angle was 83°.", + "Previous general anesthesia for cataract operation at the University Hospital in Prague was uncomplicated.", + "More information about the course of anesthesia used could not be obtained.", + "The patient was diagnosed with a patent foramen ovale.", + "The patient was diagnosed with pulmonary valve stenosis.", + "Both patent foramen ovale and pulmonary valve stenosis were hemodynamically insignificant.", + "There was no contraindication to the procedure in the prone position.", + "The patient had no significant family history.", + "Rhabdomyolysis, seizure, or CCFDN syndrome was not present in her family relatives.", + "The patient's body weight was 45 kg.", + "The patient's height was 136 cm.", + "The scoliosis curve reduced her actual height.", + "The patient's Mallampati score was 1.", + "The cardiovascular system was not affected.", + "Valve disease was insignificant.", + "The patient's ASA score was III.", + "On admission, laboratory test results were within normal limits.", + "There was no abnormality in blood count.", + "There was no abnormality in biochemical tests.", + "There was no abnormality in coagulation.", + "Pulmonary functions were dominantly limited by restrictive lung disease.", + "Forced vital capacity was 54%.", + "Forced expiratory volume in 1 s was 62%.", + "Chest X-ray was limited by chest scoliosis.", + "Chest X-ray revealed no abnormal lung and heart pathology.", + "Echocardiography found hemodynamically insignificant valve disease.", + "X-ray demonstrated a significant and progressive scoliosis curve.", + "X-ray showed a Cobb angle of 83°." + ], + "summary": "We report the anesthetic management of a 13-year-old girl with CCFDN syndrome scheduled for posterior neuromuscular scoliosis correction surgery. The patient suffered from extensive progressive neuromuscular scoliosis with a Cobb angle of 83°. Her limitations included neuropathy and a scoliotic curve. This condition negatively impacted her quality of life. This case reflects the potential anesthetic complications for posterior scoliosis correction and CCFDN syndrome. The challenge for our anesthetic team was the limited amount of data about anesthetic management of this condition. In total, one case report without any data about endotracheal intubation of patients with this condition was available. Endotracheal intubation in our case was uncomplicated. Another focus of our case was the prevention of possible complications associated with this syndrome, including rhabdomyolysis and seizures. Rhabdomyolysis can be triggered by some types of anesthetic agents like suxamethonium or volatile anesthetics, especially in patients with certain types of myopathies.", + "summary_subclaims": [ + "The patient was a 13-year-old girl with CCFDN syndrome.", + "She was scheduled for posterior neuromuscular scoliosis correction surgery.", + "She had a Cobb angle of 83°.", + "Her limitations included neuropathy and a scoliotic curve.", + "This case reflects the potential anesthetic complications for posterior scoliosis correction and CCFDN syndrome.", + "The challenge for the anesthetic team was the limited amount of data about anesthetic management of this condition.", + "One case report without any data about endotracheal intubation of patients with this condition was available.", + "Endotracheal intubation in this case was uncomplicated.", + "Another focus was the prevention of possible complications associated with this syndrome, including rhabdomyolysis and seizures.", + "Rhabdomyolysis can be triggered by some types of anesthetic agents like suxamethonium or volatile anesthetics, especially in patients with certain types of myopathies." + ] + }, + { + "id": "multiclinsum_test_3234_en.txt", + "fulltext": "An 81-year-old Korean man visited our out-patient clinic complaining of cough, dyspnea, and febrile sensation. He denied any previous medical histories. He stopped smoking tobacco 30 years ago, and never drank alcohol in recent years. His vital signs were: blood pressure 140/80 mmHg, heart rate 96 beats/minute, respiratory rate 22 breaths/minute, and body temperature 38.2 °C. On physical examination, crackle was noted in both lungs. Laboratory tests revealed a white cell count of 7800/mm3 with slight left shift (neutrophils 88.6%), C-reactive protein (CRP) level of 223.6 mg/dL (normal < 5.0 mg/dL), total bilirubin level of 1.5 mg/dL, and alanine transaminase and aspartate transaminase levels of 59 and 61 IU/L, respectively. His sodium level was 125 mEq/mL. In arterial blood gas analysis, which was checked in ambient conditions, pH, partial pressure of carbon dioxide in arterial blood (PaCO2), partial pressure of oxygen in arterial blood (PaO2), bicarbonate, and oxygen saturation levels were 7.50, 30 mmHg, 48 mmHg, 23.4 mmol/L, and 87%, respectively. The result of a test for human immunodeficiency virus was negative. Serologic tests for Mycoplasma and Chlamydia were negative. Streptococcal and Legionella urinary antigens were negative. Anti-nuclear and anti-neutrophilic cytoplasmic antibodies were negative. A chest X-ray revealed diffuse haziness dominant in his right lung field. Chest computed tomography revealed ground glass opacity in both lungs with small amounts of pleural effusion dominant in the right hemithorax. With an initial assessment of community-acquired pneumonia, we administered nasal oxygen at 4L/minute and empirical antibiotics with a respiratory quinolone. At hospital day 2, thoracentesis was conducted in the right hemithorax and a turbid yellowish fluid was obtained. Pleural fluid analysis revealed lymphocyte-dominant exudate with white cell count of 560/mm3 and adenosine deaminase level of 4.4 IU/L. On the same day, opacities were found on chest X-ray and hypoxemia rapidly progressed to require high flow oxygen supply with fraction of inspired oxygen (FiO2) 0.8 at a flow rate of 40 L/minute. At hospital day 3, he had to be intubated and mechanically ventilated due to worsening hypoxemia. The initial PaO2/FiO2 after application of mechanical ventilator was 65, which was compatible with the definition of “severe” ARDS. Potential cardiac dysfunction was ruled out using transthoracic echocardiography. Antibiotics were escalated to carbapenem. Multiplex real-time reverse transcriptase polymerase chain reaction (RT-PCR) was conducted using AdvanSureTM respiratory virus real-time RT-PCR kit (LG Life Sciences, Seoul, Korea) to detect respiratory viruses using tracheal aspirate. Results revealed positive for human RSV type B. Under the diagnosis of RSV-induced ARDS based on the Berlin definition, we started antiviral therapy of orally administered ribavirin 400 mg every 12 hours with concomitant intravenously administered methylprednisolone 30 mg every 24 hours. After treatment, hypoxemia and lung lesions gradually improved. At hospital day 17, he was extubated and we tapered methylprednisolone to orally administered prednisolone 15 mg. Finally, his chest X-ray cleared and he was discharged on hospital day 27 without any complications or drug-related adverse events. Orally administered ribavirin was maintained until his discharge.", + "fulltext_subclaims": [ + "An 81-year-old Korean man visited our out-patient clinic complaining of cough, dyspnea, and febrile sensation.", + "He denied any previous medical histories.", + "He stopped smoking tobacco 30 years ago.", + "He never drank alcohol in recent years.", + "His body temperature was 38.2 °C.", + "Crackle was noted in both lungs on physical examination.", + "Laboratory tests revealed a white cell count of 7800/mm3.", + "Neutrophils were 88.6%.", + "C-reactive protein (CRP) level was 223.6 mg/dL.", + "Total bilirubin level was 1.5 mg/dL.", + "Alanine transaminase level was 59 IU/L.", + "Aspartate transaminase level was 61 IU/L.", + "Sodium level was 125 mEq/mL.", + "Arterial blood gas analysis showed pH 7.50.", + "PaCO2 was 30 mmHg.", + "PaO2 was 48 mmHg.", + "Oxygen saturation was 87%.", + "The result of a test for human immunodeficiency virus was negative.", + "Serologic tests for Mycoplasma and Chlamydia were negative.", + "Streptococcal and Legionella urinary antigens were negative.", + "A chest X-ray revealed diffuse haziness dominant in his right lung field.", + "Chest computed tomography revealed ground glass opacity in both lungs.", + "Chest computed tomography showed small amounts of pleural effusion dominant in the right hemithorax.", + "With an initial assessment of community-acquired pneumonia, we administered nasal oxygen at 4L/minute.", + "Empirical antibiotics with a respiratory quinolone were administered.", + "At hospital day 2, thoracentesis was conducted in the right hemithorax.", + "A turbid yellowish fluid was obtained.", + "Pleural fluid analysis revealed lymphocyte-dominant exudate.", + "Pleural fluid white cell count was 560/mm3.", + "Pleural fluid adenosine deaminase level was 4.4 IU/L.", + "On the same day, opacities were found on chest X-ray.", + "Hypoxemia rapidly progressed to require high flow oxygen supply with FiO2 0.8 at a flow rate of 40 L/minute.", + "At hospital day 3, he had to be intubated and mechanically ventilated due to worsening hypoxemia.", + "The initial PaO2/FiO2 after application of mechanical ventilator was 65.", + "This PaO2/FiO2 was compatible with the definition of 'severe' ARDS.", + "Potential cardiac dysfunction was ruled out using transthoracic echocardiography.", + "Antibiotics were escalated to carbapenem.", + "Multiplex real-time reverse transcriptase polymerase chain reaction was conducted using AdvanSureTM respiratory virus real-time RT-PCR kit.", + "Results revealed positive for human RSV type B.", + "Under the diagnosis of RSV-induced ARDS based on the Berlin definition, we started antiviral therapy of orally administered ribavirin 400 mg every 12 hours.", + "Antiviral therapy included concomitant intravenously administered methylprednisolone 30 mg every 24 hours.", + "After treatment, hypoxemia and lung lesions gradually improved.", + "At hospital day 17, he was extubated.", + "Methylprednisolone was tapered to orally administered prednisolone 15 mg.", + "His chest X-ray cleared.", + "He was discharged on hospital day 27.", + "He was discharged without any complications.", + "He was discharged without any drug-related adverse events.", + "Orally administered ribavirin was maintained until his discharge." + ], + "summary": "An 81-year-old previously healthy Korean man presented with cough, dyspnea, and febrile sensation. He had hypoxemia with diffuse ground glass opacity evident on chest radiography, which progressed and required mechanical ventilation. All microbiological tests were negative except multiplex real-time reverse transcriptase polymerase chain reaction using respiratory specimen, which was positive for human adenovirus. Under the diagnosis of respiratory syncytial virus-induced acute respiratory distress syndrome, orally administered ribavirin was administered and he recuperated completely without complications.", + "summary_subclaims": [ + "The patient is an 81-year-old previously healthy Korean man.", + "The patient presented with cough, dyspnea, and febrile sensation.", + "The patient had hypoxemia.", + "Diffuse ground glass opacity was evident on chest radiography.", + "The chest radiography findings progressed.", + "The patient required mechanical ventilation.", + "All microbiological tests were negative.", + "Multiplex real-time reverse transcriptase polymerase chain reaction using respiratory specimen was positive for human adenovirus.", + "The diagnosis was respiratory syncytial virus-induced acute respiratory distress syndrome.", + "Orally administered ribavirin was administered.", + "The patient recuperated completely without complications." + ] + }, + { + "id": "multiclinsum_test_1703_en.txt", + "fulltext": "A 63-year-old man presented with a one-day history of shaking chills and high fever. He got wet in the rain 5 days before he came to the hospital, and had a occupational history of septic tank servicer. He had no underlying medical conditions, and denied travel to any areas of endemic. Physical examination revealed blood pressure (80/50 mmHg), a pulse rate of 105 beats per minute and oxygen saturation of 98% on oxygen mask air, and tachypnea with wet rales in both lungs, no conjunctival suffusion and no ictericsclera. Abdominal examination revealed a mild right abdomen tenderness and suspicious positive percussion pain in the kidney area. The rest of the examination, including nervous system, was also unremarkable. Laboratory results showed normal white blood cell (WBC) count 9.14 × 109/L with platelets 7 × 109/L, neutrophils 93.1%, and hemoglobin 85 g/L. Biochemical analysis revealed the increased levels of C-reactive protein (CRP) 209.19 mg/L, procalcitonin (PCT) 68.42ng/mL, interleukin-6 (IL-6) > 5000pg/mL, lactate 5.85mmol/L, creatinine (Cr) 301umol/L, total bilirubin 27.1µmol/L, aspartate transaminase 213.1U/L, alanine transaminase 66U/L, alkaline phosphatase 54U/L, gamma-glutamyl transferase 55U/L, and N-terminal pro b-type natriuretic peptide (NT-proBNP) 3650.97pg/ml (< 125). Arterial blood gas (ABG) analysis showed evidence of type one respiratory failure with mixed respiratory and metabolic acidosis. Urinary analysis revealed the presence of numerous WBC and red blood cells (RBC). The transthoracic echocardiography revealed an ejection fraction of 60%, normal diastolic function and chamber sizes, and color Doppler ultrasonography showed mild mitral, tricuspid and aortic regurgitation. CT examination of chest and abdomen showed inflammation of the double lower lungs, and enlarged adrenal glands . The patient was diagnosed with pneumonia, and acute pyelonephritis with septic shock, and intravenous meropenem, fluid resuscitation and vasopressor were prescribed. We implemented the sepsis protocol following the complete hour-1 bundle .\nOn the second day of admission, the patient developed gradually worsening dyspnea with severe hemoptysis and life-threatening hypoxia. Endotracheal intubation was done and patient was put on a ventilator. Immediately, large clots of blood were extracted from the endotracheal tube (ETT). Bedside chest X-ray demonstrated newly developed bilateral diffuse alveolar shadows suggesting diffuse pulmonary hemorrhages . We gave the patient a symptomatic treatment with posterior pituitary hormone, hemocoagulase, as well as blood component therapy.\nWe performed further investigations regarding the etiology of the patient’s condition. Peripheral blood Metagenomic Next-generation Sequencing (mNGS) testing [RDP-seq®, Guangzhou Sagene Biotechnology Co., Ltd.], blood and endotracheal aspirate cultures were performed. The results of all cultures were negative after 2 days of incubation. The methods for mNGS were as follows. DNA was extracted from peripheral blood samples using the microbial DNA extraction kit (MAGEN, Guangzhou, China) according to the manufacturer’s protocol. The library was constructed according to the protocol for library construction Kit [Nextera XT®, Illumina™, USA]. High-throughput sequencing was performed on the Illumina™ Nextseq 550 DX®, sequencing platform (sequencing strategy: SE75), which is an FDA-approved and CE-IVD-certified sequencer. The mNGS sequence results have been uploaded to the NCBI data (accession number: SRR24583305). The mNGS data identified Leptospira interrogans with sequence number 23 and confidence of 99%. The sequence results of identifying Leptospira interrogans were shown in Supplementary material 1. According to the clinical and microbiological findings, the antimicrobial therapy was switched to piperacillin-tazobactam (TZP) plus doxycycline.\nIntravenous TZP 4.5 g every 8 h and doxycycline 0.1 g orally every 12 h were administered, and continued for 7 days along with supportive care. Ventilator support was offered for 5 days. Finally, the patient was weaned from the ventilator for successful extubation, and improved dramatically. Normal levels of renal function, cardio-respiratory functions, and hematological parameters were also improved by the end of ten days.", + "fulltext_subclaims": [ + "The patient was a 63-year-old man.", + "He presented with a one-day history of shaking chills and high fever.", + "He got wet in the rain 5 days before he came to the hospital.", + "He had an occupational history of septic tank servicer.", + "He had no underlying medical conditions.", + "He denied travel to any areas of endemic.", + "Physical examination revealed blood pressure of 80/50 mmHg.", + "Physical examination revealed a pulse rate of 105 beats per minute.", + "Physical examination revealed oxygen saturation of 98% on oxygen mask air.", + "Physical examination revealed tachypnea with wet rales in both lungs.", + "Physical examination revealed no conjunctival suffusion.", + "Physical examination revealed no icteric sclera.", + "Abdominal examination revealed mild right abdomen tenderness.", + "Abdominal examination revealed suspicious positive percussion pain in the kidney area.", + "The rest of the examination, including nervous system, was unremarkable.", + "Laboratory results showed a white blood cell count of 9.14 × 109/L.", + "Laboratory results showed platelets of 7 × 109/L.", + "Laboratory results showed neutrophils of 93.1%.", + "Laboratory results showed hemoglobin of 85 g/L.", + "Biochemical analysis revealed C-reactive protein of 209.19 mg/L.", + "Biochemical analysis revealed procalcitonin of 68.42 ng/mL.", + "Biochemical analysis revealed interleukin-6 greater than 5000 pg/mL.", + "Biochemical analysis revealed lactate of 5.85 mmol/L.", + "Biochemical analysis revealed creatinine of 301 µmol/L.", + "Biochemical analysis revealed total bilirubin of 27.1 µmol/L.", + "Biochemical analysis revealed aspartate transaminase of 213.1 U/L.", + "Biochemical analysis revealed alanine transaminase of 66 U/L.", + "Biochemical analysis revealed alkaline phosphatase of 54 U/L.", + "Biochemical analysis revealed gamma-glutamyl transferase of 55 U/L.", + "Biochemical analysis revealed N-terminal pro b-type natriuretic peptide of 3650.97 pg/mL.", + "Arterial blood gas analysis showed evidence of type one respiratory failure with mixed respiratory and metabolic acidosis.", + "Urinary analysis revealed the presence of numerous white blood cells.", + "Urinary analysis revealed the presence of numerous red blood cells.", + "Transthoracic echocardiography revealed an ejection fraction of 60%.", + "Transthoracic echocardiography revealed normal diastolic function.", + "Transthoracic echocardiography revealed normal chamber sizes.", + "Color Doppler ultrasonography showed mild mitral regurgitation.", + "Color Doppler ultrasonography showed mild tricuspid regurgitation.", + "Color Doppler ultrasonography showed mild aortic regurgitation.", + "CT examination of chest and abdomen showed inflammation of the double lower lungs.", + "CT examination of chest and abdomen showed enlarged adrenal glands.", + "The patient was diagnosed with pneumonia.", + "The patient was diagnosed with acute pyelonephritis with septic shock.", + "Intravenous meropenem was prescribed.", + "Fluid resuscitation was prescribed.", + "Vasopressor was prescribed.", + "The sepsis protocol was implemented following the complete hour-1 bundle.", + "On the second day of admission, the patient developed gradually worsening dyspnea.", + "On the second day of admission, the patient developed severe hemoptysis.", + "On the second day of admission, the patient developed life-threatening hypoxia.", + "Endotracheal intubation was done.", + "The patient was put on a ventilator.", + "Large clots of blood were extracted from the endotracheal tube.", + "Bedside chest X-ray demonstrated newly developed bilateral diffuse alveolar shadows.", + "Bedside chest X-ray suggested diffuse pulmonary hemorrhages.", + "The patient was given symptomatic treatment with posterior pituitary hormone.", + "The patient was given symptomatic treatment with hemocoagulase.", + "The patient was given blood component therapy.", + "Peripheral blood Metagenomic Next-generation Sequencing testing was performed.", + "Blood cultures were performed.", + "Endotracheal aspirate cultures were performed.", + "The results of all cultures were negative after 2 days of incubation.", + "DNA was extracted from peripheral blood samples using the microbial DNA extraction kit.", + "The library was constructed using the Nextera XT® library construction kit.", + "High-throughput sequencing was performed on the Illumina™ Nextseq 550 DX® sequencing platform.", + "The mNGS sequence results were uploaded to the NCBI data with accession number SRR24583305.", + "The mNGS data identified Leptospira interrogans with sequence number 23.", + "The mNGS data identified Leptospira interrogans with confidence of 99%.", + "The antimicrobial therapy was switched to piperacillin-tazobactam plus doxycycline.", + "Intravenous piperacillin-tazobactam 4.5 g every 8 h was administered.", + "Doxycycline 0.1 g orally every 12 h was administered.", + "The antimicrobial therapy was continued for 7 days.", + "Ventilator support was offered for 5 days.", + "The patient was weaned from the ventilator for successful extubation.", + "The patient improved dramatically.", + "Normal levels of renal function were improved by the end of ten days.", + "Normal levels of cardio-respiratory functions were improved by the end of ten days.", + "Normal levels of hematological parameters were improved by the end of ten days." + ], + "summary": "A 63-year-old man presented with fever, shock and thrombocytopenia followed by diffuse pulmonary hemorrhage. Peripheral blood Metagenomic Next-generation Sequencing (mNGS) reported Leptospira interrogans. The patient was treated with piperacillin-tazobactam (TZP) plus doxycycline and improved dramatically after 7 days.", + "summary_subclaims": [ + "The patient was a 63-year-old man.", + "The patient presented with fever.", + "The patient presented with shock.", + "The patient presented with thrombocytopenia.", + "The patient had diffuse pulmonary hemorrhage.", + "Peripheral blood Metagenomic Next-generation Sequencing reported Leptospira interrogans.", + "The patient was treated with piperacillin-tazobactam.", + "The patient was treated with doxycycline.", + "The patient improved dramatically after 7 days." + ] + }, + { + "id": "multiclinsum_test_779_en.txt", + "fulltext": "In August 2016, an 85-year-old Iranian male with hypertension and diabetes mellitus presented with a history of dysuria, hesitancy, and urinary frequency and was found to have a urea level of 52 mg/dl and creatinine level of 1.95 mg/dl. Further investigations with the suspicion of prostate cancer were done on the patient. The Prostate-specific antigen (PSA) level was 8.9 mg/dl and suggested the possibility of prostate cancer. Magnetic resonance imaging (MRI) test showed the normal size of the prostate gland, but peripheral zone lesions were suggestive of prostate cancer. Prostate Imaging Reporting & Data System (PI-RADS) score was 5 (very suspicious). According to the PI-RADS score, direct biopsy from the lesions was recommended for the peripheral zone. The pathologic study of 12 separate samples from different areas of the prostate revealed unilateral adenocarcinoma with a histologic Gleason score of 8 (4 + 4), the malignant neoplastic proliferation of epithelial cells with a monolayer glandular design, invasion of the neighboring tissues, and desmoplastic reaction in five samples. However, the appearance of the normal texture was reported in other samples. In the whole-body scan, a bony lesion in the mid portion of the left femur was described. Hormone replacement therapy was started for him in September 2016.\nIn June 2017, the patient presented with fatigue, weight loss, and left upper quadrant pain. His Complete blood count test showed a hemoglobin level of 10.7 g/dl, mean corpuscular hemoglobin (MCH) level of 23.9, and mean corpuscular hemoglobin concentration (MCHC) level of 27.9, and an elevated RDW-CV with the value of 19.5. White blood cell (WBC) count of 171.84 109/L and platelet count of 644 109/L revealed Leukocytosis and thrombocytosis. He was suspicion of CML and was asked for quantitative reverse transcription polymerase chain reaction (QRT-PCR). Real-time PCR examination was positive for BCR/ABL P210 fusion gene t (9;22) (q34; q11), which confirmed the CML diagnosis. He started treatment with a TKI, imatinib (400 mg/daily). During the follow-ups, due to severe and symptomatic anemia, generalized edema Erythropoietin (Eprex, Epoetin Alfa®) was prescribed for the patient. Due to the treatment failure with imatinib (400 mg − 2 years), the patient was shifted to nilotinib (300 mg − 3 years), a second-generation TKI. After administration of nilotinib, the patient was not symptomatic. Quantitative BCR-ABL1 was negative, and the patient showed a deep molecular response to treatment.\nThe patient was followed up for about 5 years. In May 2021, the patient presented with nausea, lethargy, bone pain, weight loss and he had the creatinine level of 4.73 mg/dl, hemoglobin level of 7 g/dl, Erythrocyte sedimentation rate 1st hour level of 104, RBC count of 2.4 × 1012/l and Platelet count of 82 × 109/l which was indicative for anemia and renal failure. However, molecular study (quantitative assessment of BCR-ABL1) was still negative and BCR-ABL1 transcript copy was not detected. Further workup revealed a serum total protein level of 8.8 g/dl, albumin level of 3.3 g/dl, immunoglobulin (Ig) G level of 5295 mg/dl, IgA level of 22 mg/dl, IgM level of 10 mg/dl. Serum protein immunotyping (capillary Electrophoresis) detected monoclonal IgG (kappa), which may describe multiple myeloma. Urine protein electrophoresis showed negative detection of Bence Jones kappa to lambda. After injection of 99 m Tc-methylene diphosphonate (MDP), the whole-body bone scan was done with suspicious of prostate cancer bone metastasis. Thoracolumbar scoliosis, degenerative changes in the knee, shoulders and hips was noted. The bony lesion in the mid portion of the left femur were described. Regarding no changes as compared to the previous scans, these findings were not likely due to bone metastasis. Lumbar MRI did not reveal any bony lytic changes. A bone marrow biopsy revealed that 60% of nucleated cells were immature plasma cells which were suggestive of MM . The Electrodiagnosis (EDX) of the lower limbs showed no SNAPs, reduced CMAPs of bilateral peroneal nerves, and neurogenic pattern on needle EMG. Therefore, the test was abnormal and compatible with chronic sensorimotor distal polyneuropathy with axonal features. We started MP (melphalan and prednisolone) due to his neuropathy. Unfortunately, despite our treatment, he passed away after 6 months.", + "fulltext_subclaims": [ + "The patient was an 85-year-old Iranian male.", + "The patient had hypertension.", + "The patient had diabetes mellitus.", + "The patient presented with dysuria.", + "The patient presented with hesitancy.", + "The patient presented with urinary frequency.", + "The urea level was 52 mg/dl.", + "The creatinine level was 1.95 mg/dl.", + "The Prostate-specific antigen (PSA) level was 8.9 mg/dl.", + "The PSA level suggested the possibility of prostate cancer.", + "Magnetic resonance imaging (MRI) test showed the normal size of the prostate gland.", + "Peripheral zone lesions were suggestive of prostate cancer.", + "The Prostate Imaging Reporting & Data System (PI-RADS) score was 5.", + "A PI-RADS score of 5 was described as very suspicious.", + "Direct biopsy from the lesions was recommended for the peripheral zone.", + "The pathologic study of 12 separate samples from different areas of the prostate revealed unilateral adenocarcinoma.", + "The histologic Gleason score was 8 (4 + 4).", + "The malignant neoplastic proliferation of epithelial cells with a monolayer glandular design was reported.", + "Invasion of the neighboring tissues was reported in five samples.", + "Desmoplastic reaction was reported in five samples.", + "The appearance of the normal texture was reported in other samples.", + "A bony lesion in the mid portion of the left femur was described.", + "Hormone replacement therapy was started for him in September 2016.", + "In June 2017, the patient presented with fatigue.", + "In June 2017, the patient presented with weight loss.", + "In June 2017, the patient presented with left upper quadrant pain.", + "The hemoglobin level was 10.7 g/dl.", + "The mean corpuscular hemoglobin (MCH) level was 23.9.", + "The mean corpuscular hemoglobin concentration (MCHC) level was 27.9.", + "The RDW-CV was 19.5.", + "The white blood cell (WBC) count was 171.84 109/L.", + "The platelet count was 644 109/L.", + "Leukocytosis was reported.", + "Thrombocytosis was reported.", + "The patient was suspicion of CML.", + "Quantitative reverse transcription polymerase chain reaction (QRT-PCR) was requested.", + "Real-time PCR examination was positive for BCR/ABL P210 fusion gene t (9;22) (q34; q11).", + "The CML diagnosis was confirmed.", + "The patient started treatment with imatinib (400 mg/daily).", + "Erythropoietin (Eprex, Epoetin Alfa®) was prescribed due to severe and symptomatic anemia.", + "The patient was shifted to nilotinib (300 mg − 3 years) due to treatment failure with imatinib.", + "After administration of nilotinib, the patient was not symptomatic.", + "Quantitative BCR-ABL1 was negative.", + "The patient showed a deep molecular response to treatment.", + "The patient was followed up for about 5 years.", + "In May 2021, the patient presented with nausea.", + "In May 2021, the patient presented with lethargy.", + "In May 2021, the patient presented with bone pain.", + "In May 2021, the patient presented with weight loss.", + "The creatinine level was 4.73 mg/dl.", + "The hemoglobin level was 7 g/dl.", + "The Erythrocyte sedimentation rate 1st hour level was 104.", + "The RBC count was 2.4 × 1012/l.", + "The Platelet count was 82 × 109/l.", + "The molecular study (quantitative assessment of BCR-ABL1) was still negative.", + "The BCR-ABL1 transcript copy was not detected.", + "A serum total protein level of 8.8 g/dl was reported.", + "An albumin level of 3.3 g/dl was reported.", + "An immunoglobulin (Ig) G level of 5295 mg/dl was reported.", + "An IgA level of 22 mg/dl was reported.", + "An IgM level of 10 mg/dl was reported.", + "Serum protein immunotyping detected monoclonal IgG (kappa).", + "The monoclonal IgG (kappa) may describe multiple myeloma.", + "Urine protein electrophoresis showed negative detection of Bence Jones kappa to lambda.", + "The whole-body bone scan was done with suspicion of prostate cancer bone metastasis.", + "Thoracolumbar scoliosis was noted.", + "Degenerative changes in the knee, shoulders, and hips were noted.", + "The bony lesion in the mid portion of the left femur was described.", + "The findings were not likely due to bone metastasis.", + "Lumbar MRI did not reveal any bony lytic changes.", + "A bone marrow biopsy revealed that 60% of nucleated cells were immature plasma cells.", + "The immature plasma cells were suggestive of MM.", + "The Electrodiagnosis (EDX) of the lower limbs showed no SNAPs.", + "The Electrodiagnosis (EDX) of the lower limbs showed reduced CMAPs of bilateral peroneal nerves.", + "A neurogenic pattern was reported on needle EMG.", + "The test was abnormal and compatible with chronic sensorimotor distal polyneuropathy with axonal features.", + "MP (melphalan and prednisolone) was started due to his neuropathy.", + "The patient passed away after 6 months." + ], + "summary": "Herein, we reported a case of an 85-year-old Iranian male with three confirmed primary malignant neoplasms. The patient presented with synchronous prostate cancer and CML, in august 2016. He received imatinib and nilotinib for CML and hormonal therapy for prostate cancer. He remained in good control at further follow-ups for about 5 years. In the follow-up period and after 61 months treatment with tyrosine kinase inhibitors (TKIs), CML was undetectable in molecular tests, but the presence of serum M-protein, abnormal plasma cells in the bone marrow, and CRAB criteria was compatible with MM.", + "summary_subclaims": [ + "The patient was an 85-year-old Iranian male.", + "The patient had three confirmed primary malignant neoplasms.", + "The patient presented with synchronous prostate cancer and CML in August 2016.", + "The patient received imatinib and nilotinib for CML.", + "The patient received hormonal therapy for prostate cancer.", + "The patient remained in good control at further follow-ups for about 5 years.", + "After 61 months of treatment with tyrosine kinase inhibitors, CML was undetectable in molecular tests.", + "The presence of serum M-protein was noted.", + "Abnormal plasma cells were found in the bone marrow.", + "The CRAB criteria were compatible with MM." + ] + }, + { + "id": "multiclinsum_test_1586_en.txt", + "fulltext": "Without significant previous medical history, a 67-year-old Caucasian man developed spinal symptoms with temporary hypesthesia and hypoalgesia in both legs. These symptoms spontaneously resolved without any specific diagnosis at that time. At the age of 73, our patient suffered from bilateral optic neuritis and he was diagnosed with MS at an outside hospital. His expanded disability status scale (EDSS) score was at that time 2.5. Magnetic resonance imaging (MRI) studies of the spinal cord revealed a diffuse cord swelling and longitudinally extensive T2 hypertensive lesions extending from C2 to T3 (see Figure depicting a T2-weighted MRI scan, which shows residual longitudinal myelitis with extensive cord atrophy). A cranial MRI scan displayed few periventricular and cerebellar lesions without contrast enhancement and without fulfilling the Barkhof criteria. Moreover, analysis of the cerebrospinal fluid (CSF) presented oligoclonal bands. At that time, anti-AQP-4 antibody testing was not performed. A therapy with interferon beta 1a was started for six months and was replaced by interferon beta 1b at the discretion of the treating outside neurologist. Our patient developed two further spinal relapses during the treatment with interferon beta preparations. They were treated with corticosteroid pulses without any success and his EDSS score worsened from 2.5 to 4.0. Although a subsequent therapy with natalizumab was initiated at an outside clinic, our patient continued to present another three relapses. The first relapse occurred four months after starting natalizumab, the second after six months and the third relapse after eight months. All relapses repeatedly affected both optic nerves and the spinal cord each with increasing visual and motor impairment. Thus, our patient developed a high-grade spastic tetraparesis as well as impaired visual acuity of both eyes and his EDSS score progressed from 4.0 to 8.0. At that point, NMO was discussed after referral to our hospital and natalizumab therapy was discontinued after nine courses. After repeated cycles of plasma exchange, the disease course stabilized and a therapy with rituxan was started. Although B cells were completely depleted, our patient experienced another severe myelitis relapse upon further follow-up three months later. Consequently, an additional immunosuppressive therapy with cyclophosphamide at a dosage of 600mg/m2 was initiated. In the meantime, we performed repetitive anti-AQP-4 antibody tests in an approved external laboratory employing an immunofluorescence assay (IFA) cell-based analysis. Negative anti-AQP-4 antibody tests were obtained via IFA analyses upon first admission and then in six-monthly intervals after first contact at our hospital. It was only after 18 months that anti-AQP-4 antibodies became positive after three negative results. At that time, the anti-AQP-4-immunoglobulin (Ig)G antibody titer was 1:1000 while IgM and IgA titers were negative. There were no other autoantibodies and no signs of other autoimmune diseases or malignancy.\nUnder combination treatment with cyclophosphamide (13 cycles every six weeks, cumulative dosage of 8300mg/m2) followed by another cycle of rituxan, our patient developed no further relapses over an observation period of 2.5 years.", + "fulltext_subclaims": [ + "The patient is a 67-year-old Caucasian man.", + "The patient developed spinal symptoms with temporary hypesthesia and hypoalgesia in both legs.", + "The symptoms spontaneously resolved without any specific diagnosis at that time.", + "At the age of 73, the patient suffered from bilateral optic neuritis.", + "The patient was diagnosed with MS at an outside hospital.", + "The patient's EDSS score was 2.5 at the time of MS diagnosis.", + "MRI studies of the spinal cord revealed a diffuse cord swelling.", + "MRI studies showed longitudinally extensive T2 hypertensive lesions extending from C2 to T3.", + "A T2-weighted MRI scan showed residual longitudinal myelitis with extensive cord atrophy.", + "A cranial MRI scan displayed few periventricular and cerebellar lesions.", + "The cranial MRI scan showed no contrast enhancement.", + "The cranial MRI scan did not fulfill the Barkhof criteria.", + "Cerebrospinal fluid analysis presented oligoclonal bands.", + "Anti-AQP-4 antibody testing was not performed at that time.", + "A therapy with interferon beta 1a was started for six months.", + "Interferon beta 1a was replaced by interferon beta 1b at the discretion of the treating outside neurologist.", + "The patient developed two further spinal relapses during treatment with interferon beta preparations.", + "The relapses were treated with corticosteroid pulses without any success.", + "The patient's EDSS score worsened from 2.5 to 4.0.", + "A subsequent therapy with natalizumab was initiated at an outside clinic.", + "The patient continued to present three relapses during natalizumab therapy.", + "The first relapse occurred four months after starting natalizumab.", + "The second relapse occurred six months after starting natalizumab.", + "The third relapse occurred eight months after starting natalizumab.", + "All relapses repeatedly affected both optic nerves and the spinal cord.", + "The patient developed a high-grade spastic tetraparesis.", + "The patient had impaired visual acuity of both eyes.", + "The patient's EDSS score progressed from 4.0 to 8.0.", + "NMO was discussed after referral to our hospital.", + "Natalizumab therapy was discontinued after nine courses.", + "After repeated cycles of plasma exchange, the disease course stabilized.", + "A therapy with rituxan was started.", + "Although B cells were completely depleted, the patient experienced another severe myelitis relapse three months later.", + "An additional immunosuppressive therapy with cyclophosphamide at a dosage of 600mg/m2 was initiated.", + "Repetitive anti-AQP-4 antibody tests were performed in an approved external laboratory employing an immunofluorescence assay (IFA) cell-based analysis.", + "Negative anti-AQP-4 antibody tests were obtained via IFA analyses upon first admission.", + "Negative anti-AQP-4 antibody tests were obtained in six-monthly intervals after first contact at our hospital.", + "Anti-AQP-4 antibodies became positive after 18 months.", + "The anti-AQP-4-immunoglobulin (Ig)G antibody titer was 1:1000.", + "IgM and IgA titers were negative.", + "There were no other autoantibodies.", + "There were no signs of other autoimmune diseases.", + "There were no signs of malignancy.", + "Under combination treatment with cyclophosphamide (13 cycles every six weeks, cumulative dosage of 8300mg/m2) followed by another cycle of rituxan, the patient developed no further relapses over an observation period of 2.5 years." + ], + "summary": "Here, we describe a 67-year-old Caucasian man with definite neuromyelitis optica with detection of anti-aquaporin-4 antibodies over the course of the disease. After initially discussing the diagnosis of multiple sclerosis at an outside hospital, our patient received interferon beta 1a as well as repeated corticosteroid pulses without success. Under subsequent therapy with natalizumab, he continued to present relapses. It was not until discontinuation of natalizumab, repeated cycles of plasma exchanges and initiation of therapy with rituxan that the disease course started to stabilize. Although B cells were completely depleted, our patient experienced another severe myelitis relapse during further follow-up and an additional immunosuppressive therapy with cyclophosphamide was started. Under this regimen, no further relapses occurred over the next 24 months.", + "summary_subclaims": [ + "The patient is a 67-year-old Caucasian man.", + "The patient has definite neuromyelitis optica.", + "Anti-aquaporin-4 antibodies were detected over the course of the disease.", + "The patient received interferon beta 1a.", + "The patient received repeated corticosteroid pulses.", + "The patient continued to present relapses under therapy with natalizumab.", + "The disease course started to stabilize after discontinuation of natalizumab.", + "The disease course started to stabilize after repeated cycles of plasma exchanges.", + "The disease course started to stabilize after initiation of therapy with rituxan.", + "B cells were completely depleted.", + "The patient experienced another severe myelitis relapse during further follow-up.", + "An additional immunosuppressive therapy with cyclophosphamide was started.", + "No further relapses occurred over the next 24 months." + ] + }, + { + "id": "multiclinsum_test_954_en.txt", + "fulltext": "Our in-patient rheumatology service evaluated a 17-year-old Hispanic woman for pain in the neck, low back, bilateral hip, and knee as well as for headaches and morning stiffness lasting two months. At her initial hospitalization two weeks into the disease course, and at six weeks prior to rheumatology evaluation, the hospital service noted that she had decreased range of motion in her neck secondary to pain. Plain radiographic films of the cervical spine revealed no abnormalities, and she was discharged with a course of naproxen. Non-steroidal anti-inflammatory drugs (NSAIDs) offered only minimal relief of symptoms, which prompted an out-patient orthopedics community evaluation and resulted in diagnosis of 'gluteal strain' and bursitis. She was placed on propoxyphene/acetaminophen and cyclobenzaprine, but they did not improve her symptoms.\nDue to the unremitting nature of our patient's symptoms two months into her illness, her pediatrician obtained laboratory studies and a bone scan which revealed abnormal uptake in the right seventh rib (possibly due to prior fracture), increased uptake in the left distal femur and anterior superior left tibial spine, and focal uptake at the facets of several thoracic vertebrae. Her erythrocyte sedimentation rate (ESR) was 49 mm/hour and high-sensitivity C reactive protein was 44.7 mg/L. Concerned about infection or malignancy, our patient's physician readmitted her to our institution. She did not have, then or previously, a history of fever, lymphadenopathy, bleeding or easy bruisability, weight loss, gastrointestinal symptoms, cardiac murmur, or rashes. Stool guaiac results were negative, and an abdominal ultrasound showed no abnormalities. A complete blood count was without cytopenias except for mild normocytic anemia.\nA rheumatological evaluation revealed an obese (body mass index (BMI) 42, greater than 97%) adolescent with findings of point tenderness in her bilateral inferior patella, lower sacrum, and anterior hips. She had a reduced range of motion with muscle spasms in her neck, but no psoriatic lesions or nail pitting. Her spinal symptoms were most severe in the morning and improved with movement and NSAID use. Her family history was positive for idiopathic iritis (father) and inflammatory bowel disease with spondyloarthritis (paternal aunt). A rheumatoid factor was non-reactive, and anti-nuclear antibody was not detected. Creatine kinase and aldolase levels were within normal limits. A HLA-B27 marker was present in our patient. Imaging studies were consistent with an inflammatory process: a hip ultrasound revealed bilateral hip effusions, and a lower extremity MRI revealed T2 abnormal signals in patellar tendon insertions and subcutaneous tissue anterior to the inferior aspect of the left patellar tendon. Prior to her rheumatology evaluation, our patient was given celecoxib (as prescribed by her family physician), which provided significant pain relief in her back and reduction of morning stiffness. Our pediatric rheumatologist diagnosed our patient with undifferentiated spondyloarthritis using the European Spondyloarthropathy Study Group (ESSG) classification criteria (inflammatory spinal pain, hip synovitis, positive family history of HLA-B27-associated diseases, and enthesopathy/enthesitis). The family and our pediatric rheumatologists opted to keep our patient on celecoxib and have close out-patient follow-up because her musculoskeletal pain decreased and her inflammatory markers improved, Although her hip, back, and knee pain improved, our patient continued to have persistent neck pain with symptoms of occipital neuralgia after three months of scheduled NSAID therapy. New plain radiographic imaging of the cervical spine revealed a reversal of the normal lordotic curvature, and a 10 mm distance between the odontoid and anterior arches of C1 had markedly increased since prior films . A computed tomography (CT) scan of the cervical spine showed evidence of bony erosion at the tip of the odontoid as well as mild rightward rotatory subluxation of C1, with moderate cervical stenosis at C1 and minimal flattening of the spinal cord . This was confirmed on MRI , which also demonstrated inflammation around the apical and transverse ligaments and adjacent pannus formation. There was no signal abnormality within the cord itself.\nAt this point, doctors were concerned about our patient's joint instability and referred her to the neurosurgery department. She had no recent history of travel, fever, pharyngitis, torticolis, or trauma. Results of a general examination showed our patient was obese but otherwise normal. She was awake and alert, with full strength throughout. Her left upper extremity was hyper-reflexive compared to her right upper extremity, and her right lower extremity was hyper-reflexive compared to her left lower extremity. Proprioception was intact. She had up-going toes bilaterally but no clonus or Hoffman sign. She had a steady gait with no sway on Romberg testing. Because clinical and radiographic evaluations showed evidence of atlantoaxial instability in the setting of undifferentiated spondyloarthritis, our neurosurgeons recommended a C1-2 fusion to our patient and her family. The doctors postulated that inflammation-mediated ligamentous laxity was causing joint instability but that ongoing infection did not cause the cervical spine disease (Grisel's syndrome). Her anti-inflammatory medication was stopped about one week prior to surgery.\nAfter our patient was fiber-optically intubated with in-line stabilization, we placed needle electrodes for intra-operative neurophysiological monitoring. Then, we measured and recorded baseline somatosensory-evoked potentials, motor-evoked potentials, and free-run electromyography (EMG) readings from the upper and lower extremities. Our patient was then positioned prone using the Mayfield three-point fixation system and a Jackson table; there was no change in her electrophysiology monitoring after positioning. Using fluoroscopy, we checked alignment of the cervical spine, finding a decrease in the atlantodental interval from pre-operative studies. Then, we made a midline incision over the spinous processes and dissected, in standard sub-periosteal fashion, the paraspinous muscle from the spinous processes and laminae. Subsequently, we isolated and bilaterally divided the C2 nerve roots and clearly identified bilaterally the C1 lateral masses, C2 pars, and C1-2 facet complexes. Under fluoroscopic guidance, we placed C1 lateral mass screws: a 4.0 × 34 mm screw on the right and 4.0 × 32 mm screw on the left (Vertex; Medtronic Sofamor Danek, Memphis, TN USA). Then, we placed bilateral, crossing, 3.5 × 24 mm translaminar C2 screws. We performed a C1 laminectomy to ensure that the cervical cord was well decompressed; decorticated the bone; and placed the C1 laminectomy autograft over the denuded surfaces using bone morphogenetic protein (Infuse; Medtronic Sofamor Danek, Memphis, TN USA) and bone matrix (Mastergraft; Medtronic Sofamor Danek) to supplement the graft. We then placed the rods, performed the final tightening, and closed the wound in a layered fashion. Intra-operative-evoked potentials revealed no changes during the case. There was no spontaneous EMG activity. In the immediate post-operative period after waking from general anesthesia, our patient was at her baseline examination levels.\nAt two weeks after surgery, our patient was restarted on celecoxib. Poor wound healing and drainage required antibiotic coverage and delayed initiation of immunomodulation. At four weeks after surgery, our patient received a methylprednisolone infusion (1 g) and was started on adalimumab (40 mg subcutaneously every other week (actual text of hospital formulary)) eight weeks after her operation. She has had relief from neck pain and remains neurologically intact except for soft signs of myelopathy, which were found pre-operatively. There was no evidence of abnormal motion between the C1 and C2 vertebrae or evidence of instrumentation failure on dynamic cervical spine X-rays . While maintained on adalimumab, our patient has had intermittent complaints of hip and knee pain exacerbated by weather changes. Inflammatory markers have remained within normal limits since our patient started adalimumab (even during mild clinical flares). She has not developed psoriasis and there has been no evidence of sacroiliitis or irritable bowel disease (IBD) on MRI scans during a two-year follow up period.", + "fulltext_subclaims": [ + "The patient is a 17-year-old Hispanic woman.", + "She had pain in the neck, low back, bilateral hip, and knee.", + "She had headaches and morning stiffness lasting two months.", + "At her initial hospitalization two weeks into the disease course, she had decreased range of motion in her neck secondary to pain.", + "Plain radiographic films of the cervical spine revealed no abnormalities.", + "She was discharged with a course of naproxen.", + "NSAIDs offered only minimal relief of symptoms.", + "An out-patient orthopedics community evaluation resulted in diagnosis of 'gluteal strain' and bursitis.", + "She was placed on propoxyphene/acetaminophen and cyclobenzaprine.", + "Propoxyphene/acetaminophen and cyclobenzaprine did not improve her symptoms.", + "Due to the unremitting nature of her symptoms two months into her illness, her pediatrician obtained laboratory studies and a bone scan.", + "The bone scan revealed abnormal uptake in the right seventh rib.", + "The bone scan showed increased uptake in the left distal femur and anterior superior left tibial spine.", + "The bone scan showed focal uptake at the facets of several thoracic vertebrae.", + "Her ESR was 49 mm/hour.", + "Her high-sensitivity C reactive protein was 44.7 mg/L.", + "She did not have a history of fever.", + "She did not have lymphadenopathy.", + "She did not have bleeding or easy bruisability.", + "She did not have weight loss.", + "She did not have gastrointestinal symptoms.", + "She did not have a cardiac murmur.", + "She did not have rashes.", + "Stool guaiac results were negative.", + "An abdominal ultrasound showed no abnormalities.", + "A complete blood count was without cytopenias except for mild normocytic anemia.", + "A rheumatological evaluation revealed an obese adolescent with a BMI of 42.", + "She had point tenderness in her bilateral inferior patella.", + "She had point tenderness in her lower sacrum.", + "She had point tenderness in her anterior hips.", + "She had a reduced range of motion with muscle spasms in her neck.", + "She had no psoriatic lesions.", + "She had no nail pitting.", + "Her spinal symptoms were most severe in the morning.", + "Her spinal symptoms improved with movement and NSAID use.", + "Her family history was positive for idiopathic iritis (father).", + "Her family history was positive for inflammatory bowel disease with spondyloarthritis (paternal aunt).", + "Rheumatoid factor was non-reactive.", + "Anti-nuclear antibody was not detected.", + "Creatine kinase and aldolase levels were within normal limits.", + "HLA-B27 marker was present.", + "A hip ultrasound revealed bilateral hip effusions.", + "A lower extremity MRI revealed T2 abnormal signals in patellar tendon insertions.", + "A lower extremity MRI revealed subcutaneous tissue anterior to the inferior aspect of the left patellar tendon.", + "Prior to her rheumatology evaluation, she was given celecoxib.", + "Celecoxib provided significant pain relief in her back.", + "Celecoxib reduced morning stiffness.", + "The pediatric rheumatologist diagnosed undifferentiated spondyloarthritis using the ESSG classification criteria.", + "The diagnosis was based on inflammatory spinal pain.", + "The diagnosis was based on hip synovitis.", + "The diagnosis was based on positive family history of HLA-B27-associated diseases.", + "The diagnosis was based on enthesopathy/enthesitis.", + "The family and pediatric rheumatologists opted to keep her on celecoxib.", + "The family and pediatric rheumatologists opted for close out-patient follow-up.", + "Her musculoskeletal pain decreased.", + "Her inflammatory markers improved.", + "Her hip, back, and knee pain improved.", + "She continued to have persistent neck pain with symptoms of occipital neuralgia after three months of scheduled NSAID therapy.", + "New plain radiographic imaging of the cervical spine revealed a reversal of the normal lordotic curvature.", + "A 10 mm distance between the odontoid and anterior arches of C1 had markedly increased since prior films.", + "A CT scan of the cervical spine showed evidence of bony erosion at the tip of the odontoid.", + "A CT scan showed mild rightward rotatory subluxation of C1.", + "A CT scan showed moderate cervical stenosis at C1.", + "A CT scan showed minimal flattening of the spinal cord.", + "This was confirmed on MRI.", + "MRI demonstrated inflammation around the apical and transverse ligaments.", + "MRI demonstrated adjacent pannus formation.", + "There was no signal abnormality within the cord itself.", + "Doctors were concerned about joint instability.", + "She was referred to the neurosurgery department.", + "She had no recent history of travel.", + "She had no recent history of fever.", + "She had no recent history of pharyngitis.", + "She had no recent history of torticolis.", + "She had no recent history of trauma.", + "Results of a general examination showed she was obese.", + "She was awake and alert.", + "She had full strength throughout.", + "Her left upper extremity was hyper-reflexive compared to her right upper extremity.", + "Her right lower extremity was hyper-reflexive compared to her left lower extremity.", + "Proprioception was intact.", + "She had up-going toes bilaterally.", + "She had no clonus.", + "She had no Hoffman sign.", + "She had a steady gait.", + "She had no sway on Romberg testing.", + "Clinical and radiographic evaluations showed evidence of atlantoaxial instability.", + "This was in the setting of undifferentiated spondyloarthritis.", + "Neurosurgeons recommended a C1-2 fusion.", + "Doctors postulated that inflammation-mediated ligamentous laxity was causing joint instability.", + "Ongoing infection did not cause the cervical spine disease.", + "Her anti-inflammatory medication was stopped about one week prior to surgery.", + "She was fiber-optically intubated with in-line stabilization.", + "Needle electrodes were placed for intra-operative neurophysiological monitoring.", + "Baseline somatosensory-evoked potentials were measured.", + "Baseline motor-evoked potentials were measured.", + "Baseline free-run EMG readings were recorded.", + "She was positioned prone using the Mayfield three-point fixation system.", + "There was no change in electrophysiology monitoring after positioning.", + "Fluoroscopy showed a decrease in the atlantodental interval from pre-operative studies.", + "A midline incision was made over the spinous processes.", + "Paraspinous muscle was dissected in standard sub-periosteal fashion.", + "C2 nerve roots were bilaterally divided.", + "C1 lateral masses, C2 pars, and C1-2 facet complexes were bilaterally identified.", + "C1 lateral mass screws were placed under fluoroscopic guidance.", + "A 4.0 × 34 mm screw was placed on the right.", + "A 4.0 × 32 mm screw was placed on the left.", + "Bilateral, crossing, 3.5 × 24 mm translaminar C2 screws were placed.", + "A C1 laminectomy was performed to ensure cervical cord decompression.", + "The bone was decorticated.", + "The C1 laminectomy autograft was placed over the denuded surfaces.", + "Bone morphogenetic protein and bone matrix were used to supplement the graft.", + "Rods were placed.", + "Final tightening was performed.", + "The wound was closed in a layered fashion.", + "Intra-operative-evoked potentials revealed no changes during the case.", + "There was no spontaneous EMG activity.", + "In the immediate post-operative period, she was at her baseline examination levels.", + "At two weeks after surgery, she was restarted on celecoxib.", + "Poor wound healing and drainage required antibiotic coverage.", + "Delayed initiation of immunomodulation was necessary.", + "At four weeks after surgery, she received a methylprednisolone infusion (1 g).", + "She was started on adalimumab (40 mg subcutaneously every other week).", + "She has had relief from neck pain.", + "She remains neurologically intact except for soft signs of myelopathy.", + "There was no evidence of abnormal motion between C1 and C2 vertebrae.", + "There was no evidence of instrumentation failure on dynamic cervical spine X-rays.", + "Inflammatory markers have remained within normal limits since starting adalimumab.", + "She has had intermittent complaints of hip and knee pain exacerbated by weather changes.", + "She has not developed psoriasis.", + "There has been no evidence of sacroiliitis on MRI scans during a two-year follow up period.", + "There has been no evidence of irritable bowel disease on MRI scans during a two-year follow up period." + ], + "summary": "We report the case of a 17-year-old Hispanic adolescent woman who was initially diagnosed with undifferentiated spondyloarthritis due to peripheral arthritis, enthesitis, a positive human leukocyte antigen B27 result, and inflammatory spinal pain lasting two months. Our patient experienced persistent and worsening occipitocervical pain and signs of myelopathy three months after diagnosis; consequently, we found atlantoaxial instability along with cervical spine bone erosion and pannus formation. She was treated surgically with a C1-2 posterior instrumented fusion and at six weeks post-operatively was started on tumor necrosis factor α blockade. Her occipitocervical symptoms subsided following surgery and initiation of immunomodulation.", + "summary_subclaims": [ + "The patient was a 17-year-old Hispanic adolescent woman.", + "She was initially diagnosed with undifferentiated spondyloarthritis.", + "The diagnosis was based on peripheral arthritis.", + "The diagnosis was based on enthesitis.", + "The diagnosis was based on a positive human leukocyte antigen B27 result.", + "The diagnosis was based on inflammatory spinal pain lasting two months.", + "She experienced persistent and worsening occipitocervical pain.", + "She had signs of myelopathy three months after diagnosis.", + "Atlantoaxial instability was found.", + "Cervical spine bone erosion was found.", + "Pannus formation was found.", + "She was treated surgically with a C1-2 posterior instrumented fusion.", + "She was started on tumor necrosis factor α blockade six weeks post-operatively.", + "Her occipitocervical symptoms subsided following surgery.", + "Her occipitocervical symptoms subsided following initiation of immunomodulation." + ] + }, + { + "id": "multiclinsum_test_3005_en.txt", + "fulltext": "23-year-old woman (gestation 2, 1 delivery) who consulted our institution in the 36.5th week of gestation for dry cough and progressive dyspnoea of three days' evolution, associated with myalgia and headaches. She was admitted tachycardic (120 beats per minute), afebrile and oxygen saturation of 96% in ambient air. In the context of a pandemic, a PCR was performed for SARS-CoV2 with a positive result. The chest radiograph was interpreted as normal. The patient began with contractions of labour, showing an unfavourable Bishop's score. In view of the lack of progression of labour, the pregnancy was terminated by caesarean section. Initial laboratory tests (pre-caesarean section) were requested, showing mild anaemia (Hb: 10.8 g%), mild platelet deficiency (123,000/mm3), altered hepatic profile: total bilirubin: 3.5 mg%, direct bilirubin: 3.3 mg%, glutamic-pyruvic transaminase (GPT): 564 IU/l, glutamic-oxaloacetic transaminase (GPT): 692 IU/l, alkaline phosphatase (AP): 337 IU/l and elevated LDH: 814 IU/l. Caesarean section was performed without complications, resulting in a healthy newborn, Apgar 8/9, Capurro 37 weeks, of adequate weight for the gestational age. Bupivacaine was used as a spinal anaesthetic. During the procedure, systolic blood pressure remained between 100 and 120 mmHg and diastolic blood pressure between 60 and 80 mmHg, with oxygen saturation of 98%. After the caesarean section, the patient was transferred to intensive care for adequate monitoring. Blood gases were measured (oxygen fraction inspired 21%), with the following results: pH: 7.17, pCO2: 23 mmHg, pO2: 115 mmHg - Bicarbonate: 8.1 mEq/l, excess base: -19 mEq/l - oxygen saturation: 96% and lactic acid: 11.4 mmoles/l. She received supportive treatment and a large amount of Ringer lactate with progressive improvement of the laboratory parameters. The parameters normalised after 72 hours. Respiratory compromise was mild, allowing discharge a few days later. The newborn did not present complications.\n", + "fulltext_subclaims": [ + "The patient is a 23-year-old woman.", + "She is in the 36.5th week of gestation.", + "She had dry cough and progressive dyspnoea for three days.", + "She had myalgia and headaches.", + "She was admitted tachycardic with a heart rate of 120 beats per minute.", + "She was afebrile.", + "Her oxygen saturation was 96% in ambient air.", + "A PCR for SARS-CoV2 was performed.", + "The PCR for SARS-CoV2 was positive.", + "The chest radiograph was interpreted as normal.", + "The patient began with contractions of labour.", + "The Bishop's score was unfavourable.", + "The pregnancy was terminated by caesarean section.", + "Initial laboratory tests showed mild anaemia with Hb: 10.8 g%.", + "Initial laboratory tests showed mild platelet deficiency with 123,000/mm3.", + "Total bilirubin was 3.5 mg%.", + "Direct bilirubin was 3.3 mg%.", + "GPT was 564 IU/l.", + "GOT was 692 IU/l.", + "Alkaline phosphatase was 337 IU/l.", + "LDH was 814 IU/l.", + "The caesarean section was performed without complications.", + "The newborn had an Apgar score of 8/9.", + "The newborn was 37 weeks gestational age.", + "The newborn was of adequate weight for gestational age.", + "Bupivacaine was used as a spinal anaesthetic.", + "Systolic blood pressure during the procedure remained between 100 and 120 mmHg.", + "Diastolic blood pressure during the procedure remained between 60 and 80 mmHg.", + "Oxygen saturation during the procedure was 98%.", + "The patient was transferred to intensive care after the caesarean section.", + "Blood gases showed pH: 7.17.", + "Blood gases showed pCO2: 23 mmHg.", + "Blood gases showed pO2: 115 mmHg.", + "Bicarbonate was 8.1 mEq/l.", + "Excess base was -19 mEq/l.", + "Oxygen saturation was 96%.", + "Lactic acid was 11.4 mmoles/l.", + "She received supportive treatment.", + "She received a large amount of Ringer lactate.", + "Laboratory parameters normalised after 72 hours.", + "Respiratory compromise was mild.", + "The patient was discharged a few days later.", + "The newborn did not present complications." + ], + "summary": "A pregnant woman in her 36th week of pregnancy presented to the emergency department with a dry cough and progressive dyspnoea of 3 days duration associated with headaches and myalgia. A nasopharyngeal swab for polymerase chain reaction (PCR) for SARS-CoV-2 was positive. Oxygen saturation was normal, as was the chest radiograph. In the laboratory she presented elevated bilirubin, transaminases, alkaline phosphatase and LDH, as well as mild platelopenia. Shortly after admission, she began labour. In the absence of progress, it was decided to terminate the pregnancy by caesarean section. Arterial blood gas revealed the presence of severe lactic acidosis. There was never clinical evidence of tissue hypoperfusion or sepsis that could explain it. She was in the intensive care unit for her postoperative treatment. All laboratory parameters normalised after 72 hours, and she made a favourable clinical evolution. She was interpreted as having partial HELLP syndrome.\n", + "summary_subclaims": [ + "A pregnant woman in her 36th week of pregnancy presented to the emergency department with a dry cough and progressive dyspnoea of 3 days duration associated with headaches and myalgia.", + "A nasopharyngeal swab for polymerase chain reaction (PCR) for SARS-CoV-2 was positive.", + "Oxygen saturation was normal.", + "The chest radiograph was normal.", + "In the laboratory she presented elevated bilirubin, transaminases, alkaline phosphatase and LDH, as well as mild platelopenia.", + "Shortly after admission, she began labour.", + "It was decided to terminate the pregnancy by caesarean section.", + "Arterial blood gas revealed the presence of severe lactic acidosis.", + "There was never clinical evidence of tissue hypoperfusion or sepsis that could explain it.", + "She was in the intensive care unit for her postoperative treatment.", + "All laboratory parameters normalised after 72 hours.", + "She made a favourable clinical evolution.", + "She was interpreted as having partial HELLP syndrome." + ] + }, + { + "id": "multiclinsum_test_221_en.txt", + "fulltext": "A 65-year-old Moroccan man with a history of diabetes and cigarette smoking had no relevant exposure to chemical industrial products in the past, and no notable surgical or family history.\nThe patient presented 3 months before his medical consult with macroscopic hematuria, pollakiuria, and painful urination, without acute urine retention or digestive disorders, evolving in a context of conservation of the general state. Physical examination did not reveal any abnormalities. No mass was palpable on clinical examination of the abdomen.\nPelvic ultrasound showed an echogenic irregular mass on the left lateral wall of the bladder associated with soft dilatation of the upper urinary tract . The baseline blood workup, including NSF and Glomerular Filtration Rate, did not reveal any abnormality.\nCystoscopy revealed a non-papillary massive mass on the left lateral wall of the bladder, and a transurethral resection of the bladder tumor (TURBT) was performed at the same time. Pelvic MRI was not done due to lack of means.\nHistopathological analysis of the resected tissues showed a biphasic epithelial and mesenchymal proliferation, with invasion of the lamina propria and muscularis, compatible with the diagnosis of bladder carcinosarcoma, stage pT2. The transurethral resection was complete.\nStaging including pelvic CT scan revealed a heterogeneous mass of the dome and the left wall of the bladder, measuring 10 × 6 cm, invading the bladder wall until serosa . There were no iliac lymph nodes, the ipsilateral ureteral orifice was intact, and there weren't any signs of upper urinary tract obstruction. Thoraco-abdominal CT, as well as bone scan, were free of metastasis. The patient was classified as T3N0M0.\nAfter urology tumor board meeting, the patient underwent radical cystoprostatectomy with ileal conduit urinary diversion (Bricker), and an extended pelvic lymph node dissection. There were no post-operative complications. Histopathological examination of the specimen revealed a high-grade carcinosarcoma invading the bladder wall until the serosa and the trigone, with the prostate and the urethra free from tumor extension. Two of eight pelvic lymph nodes were positive for metastatic carcinosarcoma without extra-nodal extension. All surgical margins were negative for tumor. Immunohistochemistry showed positivity of Pan-cytokeratin, GATA3, and vimentin, and negativity for CK7, myogenin, desmin, and PSA .\nAfter discussion with the multidisciplinary board, an adjuvant chemotherapy based on gemcitabine-cisplatin was indicated, and a total of six cycles were received with no significant toxicity. The patient was scheduled for trimestrial clinical visits, Cystoscopy · months after finishing treatment, UroTDM performed each semester. Twelve months after treatment, the patient is still under follow-up with no locoregional or metastatic disease.", + "fulltext_subclaims": [ + "The patient is a 65-year-old Moroccan man.", + "The patient has a history of diabetes.", + "The patient has a history of cigarette smoking.", + "The patient had no relevant exposure to chemical industrial products in the past.", + "The patient had no notable surgical history.", + "The patient had no notable family history.", + "The patient presented 3 months before his medical consult with macroscopic hematuria.", + "The patient presented 3 months before his medical consult with pollakiuria.", + "The patient presented 3 months before his medical consult with painful urination.", + "The patient did not have acute urine retention.", + "The patient did not have digestive disorders.", + "The patient's general state was conserved.", + "Physical examination did not reveal any abnormalities.", + "No mass was palpable on clinical examination of the abdomen.", + "Pelvic ultrasound showed an echogenic irregular mass on the left lateral wall of the bladder.", + "Pelvic ultrasound showed soft dilatation of the upper urinary tract.", + "Baseline blood workup did not reveal any abnormality.", + "Cystoscopy revealed a non-papillary massive mass on the left lateral wall of the bladder.", + "A transurethral resection of the bladder tumor (TURBT) was performed.", + "Histopathological analysis showed a biphasic epithelial and mesenchymal proliferation.", + "Histopathological analysis showed invasion of the lamina propria and muscularis.", + "The histopathological findings were compatible with the diagnosis of bladder carcinosarcoma.", + "The tumor stage was pT2.", + "The transurethral resection was complete.", + "Staging included a pelvic CT scan.", + "The mass measured 10 × 6 cm.", + "The mass invaded the bladder wall until serosa.", + "There were no iliac lymph nodes.", + "The ipsilateral ureteral orifice was intact.", + "There were no signs of upper urinary tract obstruction.", + "Thoraco-abdominal CT was free of metastasis.", + "Bone scan was free of metastasis.", + "The patient was classified as T3N0M0.", + "The patient underwent radical cystoprostatectomy with ileal conduit urinary diversion (Bricker).", + "An extended pelvic lymph node dissection was performed.", + "There were no post-operative complications.", + "Histopathological examination revealed a high-grade carcinosarcoma invading the bladder wall until the serosa and the trigone.", + "The prostate and the urethra were free from tumor extension.", + "Two of eight pelvic lymph nodes were positive for metastatic carcinosarcoma.", + "All surgical margins were negative for tumor.", + "Immunohistochemistry showed positivity of Pan-cytokeratin.", + "Immunohistochemistry showed positivity of GATA3.", + "Immunohistochemistry showed positivity of vimentin.", + "Immunohistochemistry showed negativity for CK7.", + "Immunohistochemistry showed negativity for myogenin.", + "Immunohistochemistry showed negativity for desmin.", + "Immunohistochemistry showed negativity for PSA.", + "An adjuvant chemotherapy based on gemcitabine-cisplatin was indicated.", + "A total of six cycles of chemotherapy were received.", + "The patient received chemotherapy with no significant toxicity.", + "The patient was scheduled for trimestrial clinical visits.", + "The patient was scheduled for cystoscopy months after finishing treatment.", + "The patient was scheduled for UroTDM performed each semester.", + "Twelve months after treatment, the patient is still under follow-up.", + "Twelve months after treatment, there is no locoregional or metastatic disease." + ], + "summary": "We report a case of 65-year-old Moroccan man, presented with macroscopic hematuria, pollakiuria and painful urination. Histological analysis showed a biphasic epithelial and mesenchymal proliferation, with invasion of lamina propria and muscularis, compatible with diagnosis of bladder carcinosarcoma. The patient was treated with cystectomy and adjuvant chemotherapy based on gemcitabin-cisplatin, 18 months after treatment, patient still free of recurrence.", + "summary_subclaims": [ + "The patient is a 65-year-old Moroccan man.", + "The patient presented with macroscopic hematuria.", + "The patient had pollakiuria.", + "The patient had painful urination.", + "Histological analysis showed a biphasic epithelial and mesenchymal proliferation.", + "The histological findings showed invasion of lamina propria.", + "The histological findings showed invasion of muscularis.", + "The histological findings were compatible with diagnosis of bladder carcinosarcoma.", + "The patient was treated with cystectomy.", + "The patient received adjuvant chemotherapy based on gemcitabin-cisplatin.", + "Eighteen months after treatment, the patient was still free of recurrence." + ] + }, + { + "id": "multiclinsum_test_2284_en.txt", + "fulltext": "A 30-year-old male, right-handed, manual laborer presented with an insidious onset and gradually progressive right shoulder pain with a feeling of instability for 5 months. For these complaints, the patient visited the outpatient department. On examination, the patient was apprehensive of external rotation beyond 60°. The patient had an anterior drawer test and sulcus sign positive . The patient had pain while initiating abduction. The range of abduction, however, was equal as compared to the opposite side. There was no pain or restriction of range on adduction and internal rotation. The impact maneuvers (Neer and Hawkins) were negative. There was no tenderness on palpation of the bicipital groove. Radiological investigations in the form of radiogram and magnetic resonance imaging were performed. Partial-thickness supraspinatus tear and fraying of the anteroinferior glenoid labrum were noted in the imaging.\nThe patient was advised conservative line of management with analgesics and physiotherapeutic rehabilitation for a period of 3 months. After the completion of this conservative treatment protocol, the patient presented for follow-up with persistence of pain. The patient was posted for an arthroscopic repair of the supraspinatus tear and the anteroinferior glenoid labrum. During the arthroscopic procedure, a variation in the anatomical origin of the long head of biceps was noted; the origin was on the inferior surface of the supraspinatus . This tendon of long head of biceps was not found to be inflamed or degenerated and was stable on probing. Arthroscopic repair of the supraspinatus tendon and capsulolabral reinforcement was performed using absorbable anchors.\nThe tendon of long head of the biceps was not operated on. On 1-month follow-up, the pain had significantly decreased and the complaint of instability was also completely resolved. The patient resumed work after 6 months of rehabilitation.", + "fulltext_subclaims": [ + "The patient is a 30-year-old male.", + "The patient is right-handed.", + "The patient is a manual laborer.", + "The patient had an insidious onset of right shoulder pain.", + "The right shoulder pain was gradually progressive.", + "The patient had a feeling of instability in the right shoulder.", + "The symptoms lasted for 5 months.", + "The patient was apprehensive of external rotation beyond 60°.", + "The anterior drawer test was positive.", + "The sulcus sign was positive.", + "The patient had pain while initiating abduction.", + "The range of abduction was equal as compared to the opposite side.", + "There was no pain or restriction of range on adduction.", + "There was no restriction of range on internal rotation.", + "The impact maneuvers (Neer and Hawkins) were negative.", + "There was no tenderness on palpation of the bicipital groove.", + "Radiological investigations included a radiogram and magnetic resonance imaging.", + "A partial-thickness supraspinatus tear was noted in the imaging.", + "Fraying of the anteroinferior glenoid labrum was noted in the imaging.", + "The patient was advised conservative management with analgesics and physiotherapeutic rehabilitation.", + "The conservative treatment protocol lasted for 3 months.", + "The patient presented for follow-up after completing the conservative treatment.", + "The patient had persistence of pain after the conservative treatment.", + "The patient was posted for an arthroscopic repair of the supraspinatus tear.", + "The patient was posted for an arthroscopic repair of the anteroinferior glenoid labrum.", + "During the arthroscopic procedure, a variation in the anatomical origin of the long head of biceps was noted.", + "The origin of the long head of biceps was on the inferior surface of the supraspinatus.", + "The tendon of the long head of biceps was not found to be inflamed.", + "The tendon of the long head of biceps was not found to be degenerated.", + "The tendon of the long head of biceps was stable on probing.", + "Arthroscopic repair of the supraspinatus tendon was performed.", + "Capsulolabral reinforcement was performed using absorbable anchors.", + "The tendon of the long head of the biceps was not operated on.", + "On 1-month follow-up, the pain had significantly decreased.", + "The complaint of instability was completely resolved on 1-month follow-up.", + "The patient resumed work after 6 months of rehabilitation." + ], + "summary": "Here, we discuss a case of a rare anatomical variant of the origin of long head of biceps tendon discovered incidentally in a 30-year-old manual laborer. The patient had an insidious onset and gradually progressive right shoulder pain, especially in initiating abduction, with a feeling of instability for 5 months. On examination, apprehension test and anterior drawer test were present and sulcus sign was positive. Partial-thickness supraspinatus tear and fraying of the anteroinferior glenoid labrum were noted in the imaging. After giving a fair trial of conservative management, the patient was posted for an arthroscopic repair of the supraspinatus tear and the anteroinferior glenoid labrum when the anomalous origin of the tendon of long head of biceps was discovered incidentally. This origin was from the inferior surface of the supraspinatus muscle outside the capsule. The tendon was left intact as it was not found to be inflamed or degenerated and was not the source of instability.", + "summary_subclaims": [ + "The patient was a 30-year-old manual laborer.", + "The patient had an insidious onset and gradually progressive right shoulder pain.", + "The pain was especially in initiating abduction.", + "The patient had a feeling of instability for 5 months.", + "Apprehension test was present.", + "Anterior drawer test was present.", + "Sulcus sign was positive.", + "Partial-thickness supraspinatus tear was noted in the imaging.", + "Fraying of the anteroinferior glenoid labrum was noted in the imaging.", + "The patient was given a fair trial of conservative management.", + "The patient was posted for an arthroscopic repair of the supraspinatus tear.", + "The patient was posted for an arthroscopic repair of the anteroinferior glenoid labrum.", + "An anomalous origin of the tendon of long head of biceps was discovered incidentally.", + "The origin was from the inferior surface of the supraspinatus muscle.", + "The origin was outside the capsule.", + "The tendon was left intact.", + "The tendon was not found to be inflamed.", + "The tendon was not found to be degenerated.", + "The tendon was not the source of instability." + ] + }, + { + "id": "multiclinsum_test_2194_en.txt", + "fulltext": "A 55-year-old male patient had presented to us in the outpatient department with a gradually progressive swelling over ankle anteriorly, noticeable for the past 15 years. The swelling was globular, bony hard to feel and non-fluctuant in nature. It measured 100 × 70 × 50 mm clinically . The overlying skin was non-adherent to the underlying swelling, with no local signs of inflammation. Examination revealed dorsiflexion of the ankle beyond neutral to be restricted; however, plantar flexion was preserved. The subtalar movements were unaffected. There was no evidence of compression symptoms of the neurovascular structures in the vicinity.\nOn radiographic evaluation, there was a huge anteromedial bony swelling originating from the neck of the talus and abutting the distal tibia . Computed tomography scan suggested a benign bony mass originating from the talar neck, likely to be osteochondroma . In view of the long-standing nature and benign radiographic appearance, the patient was planned for excisional biopsy of the swelling.\nThe patient was operated in supine position, and a single anteromedial incision was given . The lesion was well-encapsulated and well-marginated from the surrounding soft tissues. It was excised en-mass, following osteotomy from the base and sent for histopathological examination (HPE) . The HPE showed the lesion to be an osteochondroma . The skin was closed primarily, and the redundant skin was left intact. A well-padded compressive dressing was done for a period of 02 weeks. Post-operative radiographs revealed complete removal of the lesion with a congruent mortise.\nThe patient was full weight-bearing ambulant from post-operative day 1. The dorsiflexion of the ankle improved to 30°. The patient essentially had an uneventful recovery.", + "fulltext_subclaims": [ + "The patient is a 55-year-old male.", + "The patient had a gradually progressive swelling over the ankle anteriorly.", + "The swelling was noticeable for the past 15 years.", + "The swelling was globular, bony hard to feel, and non-fluctuant.", + "The swelling measured 100 × 70 × 50 mm clinically.", + "The overlying skin was non-adherent to the underlying swelling.", + "There were no local signs of inflammation.", + "Dorsiflexion of the ankle beyond neutral was restricted.", + "Plantar flexion was preserved.", + "The subtalar movements were unaffected.", + "There was no evidence of compression symptoms of the neurovascular structures.", + "Radiographic evaluation showed a huge anteromedial bony swelling originating from the neck of the talus.", + "The swelling abutted the distal tibia.", + "Computed tomography scan suggested a benign bony mass originating from the talar neck.", + "The mass was likely to be osteochondroma.", + "The patient was planned for excisional biopsy of the swelling.", + "The patient was operated in the supine position.", + "A single anteromedial incision was given.", + "The lesion was well-encapsulated and well-marginated from the surrounding soft tissues.", + "The lesion was excised en-mass following osteotomy from the base.", + "The lesion was sent for histopathological examination.", + "The histopathological examination showed the lesion to be an osteochondroma.", + "The skin was closed primarily.", + "The redundant skin was left intact.", + "A well-padded compressive dressing was done for a period of 02 weeks.", + "Post-operative radiographs revealed complete removal of the lesion.", + "The mortise was congruent after surgery.", + "The patient was full weight-bearing ambulant from post-operative day 1.", + "The dorsiflexion of the ankle improved to 30°.", + "The patient had an uneventful recovery." + ], + "summary": "We present a case of a 55-year-old male patient with a giant osteochondroma originating from the neck of the talus. The patient presented with a huge 100 × 70 × 50 mm swelling over the ankle. The patient underwent an excision of the swelling. Histopathological examination of the swelling confirmed the findings of an osteochondroma. The patient had an uneventful recovery after the excision and resumed his functional activity completely.", + "summary_subclaims": [ + "The patient is a 55-year-old male.", + "The patient had a giant osteochondroma originating from the neck of the talus.", + "The patient had a 100 × 70 × 50 mm swelling over the ankle.", + "The patient underwent excision of the swelling.", + "Histopathological examination of the swelling confirmed the findings of an osteochondroma.", + "The patient had an uneventful recovery after the excision.", + "The patient resumed his functional activity completely." + ] + }, + { + "id": "multiclinsum_test_247_en.txt", + "fulltext": "We present the case of a 57 year-old woman on follow-up in primary care for a four-year history of mild hyperkalemia [range 5.3–5.9 mmol/L (reference range: 3.5–5.1 mmol/L)] without associated hemolysis (spectrophotometric hemolysis index <6 mg/dL in all laboratory reports). The patient did not exhibit any associated signs or symptoms. Control electrocardiograms were normal, without significant findings. Her medical history included arterial hypertension, adequately controlled with ACE inhibitors. In this context, the patient was referred to the Unit of Nephrology for further examination.\nAnamnesis and physical examination did not reveal any data of interest. The patient was receiving amlodipine for arterial hypertension, with good control. Control electrocardiogram was normal. A potassium-low diet and control laboratory analysis in three months were indicated. Three months later, a control blood analysis was performed. The laboratory received a sample of serum and a request for determination of potassium alone. The sample was not hemolyzed (hemolysis index <6 mg/dL) and showed mild hyperkalemia of 5.5 mmol/L. Once pre-analytical and drug-related causes were excluded, differential diagnosis was performed, including:Hyperkalemia secondary to renal insufficiency. Hyperkalemia secondary to intravascular hemolysis. Hyperkalemia secondary to acidosis. Hyperkalemia secondary to tissue breakdown (rhabdomyolysis). Pseudohyperkalemia secondary to oncohematologic disease (essential thrombocytosis, acute or chronic leukemia).\nFor differential diagnosis in the laboratory, blood was drawn at the hospital and sent to the laboratory with the following tests request: Hemogram including reticulocytes and blood smear. General biochemistry including ions, hemolysis index, hepatic profile (GOT, GPT, GGT, LDH, and ALP), renal profile (creatinine, urea, and estimated glomerular filtration rate CKD-EPI), creatine kinase, haptoglobin, phosphocalcic, and iron metabolism (iron, transferrin saturation index, transferrin, and ferritin). Venous gasometry: Blood gas test is immediately performed with a pH of 7.39 (range of reference 7.35–7.45). 24-urine biochemistry.\nAn EDTA sample was sent to obtain a hemogram and a lithium heparin sample for biochemistry. Smear was normal, without morphological alterations. All parameters in the hemogram were within normal range, with 1.55% reticulocytes (range of reference: 0.9–2.6%). Oncohematologic diseases were excluded by differential diagnosis.\nThe only finding on general biochemistry was cholesterol 248 mg/dL (range of reference: <200 mg/dL), with potassium 3.98 mmol/L (range of reference in plasma: 3.4–4.5 mmol/L), creatinine 0.86 mg/dL (range of reference: 0.51–0.95 mg/dL), and haptoglobin 39 mg/dL (range of reference: 30–200 mg/dL), and a hemolysis index <6 mg/dL. PCR, CK, hepatic profile and other parameters were within normal range. Laboratory analysis excluded hyperkalemia, due to the absence of renal insufficiency or data of cellular lysis or signs of intravascular hemolysis. Urine biochemistry was normal, with all parameters within normal range.\nOnce all potential causes were excluded by differential diagnosis, and in the absence of elevated potassium levels, a possible case of familial pseudohyperkalemia was considered. Three lithium heparin tubes were collected at the hospital for incubation at different time points and temperatures: Two aliquots for incubation at 4 °C for 2 and 4 h, respectively. This simulated transport conditions from the primary care center to the laboratory, since samples are transported at 4 °C for a mean of 3 h. Two aliquots for incubation at 25 °C for 2 and 4 h, respectively. This simulates transport conditions from the room where blood is drawn to the laboratory, since samples are transported at room temperature for a mean of 3 h. Two aliquots for incubation at 37 °C for 2 and 4 h, respectively. This simulates in vivo conditions.\nUncentrifuged samples were received for analysis. Centrifugation was performed after the incubation period was completed (results shown in ). In parallel, a negative control was performed (Results shown in ).", + "fulltext_subclaims": [ + "The patient is a 57 year-old woman.", + "The patient has a four-year history of mild hyperkalemia.", + "The potassium range was 5.3–5.9 mmol/L.", + "The reference range for potassium is 3.5–5.1 mmol/L.", + "There was no associated hemolysis.", + "The spectrophotometric hemolysis index was <6 mg/dL in all laboratory reports.", + "The patient did not exhibit any associated signs or symptoms.", + "Control electrocardiograms were normal.", + "The patient's medical history included arterial hypertension.", + "The patient was on ACE inhibitors.", + "The patient was referred to the Unit of Nephrology for further examination.", + "The patient was receiving amlodipine for arterial hypertension.", + "A potassium-low diet was indicated.", + "Control laboratory analysis was scheduled in three months.", + "A control blood analysis was performed three months later.", + "The laboratory received a sample of serum.", + "The sample was not hemolyzed.", + "The potassium level was 5.5 mmol/L.", + "Pre-analytical and drug-related causes were excluded.", + "Differential diagnosis included hyperkalemia secondary to renal insufficiency.", + "Differential diagnosis included hyperkalemia secondary to intravascular hemolysis.", + "Differential diagnosis included hyperkalemia secondary to acidosis.", + "Differential diagnosis included hyperkalemia secondary to tissue breakdown.", + "Differential diagnosis included pseudohyperkalemia secondary to oncohematologic disease.", + "Blood was drawn at the hospital.", + "The blood gas test was immediately performed.", + "The pH was 7.39.", + "The reference range for pH is 7.35–7.45.", + "An EDTA sample was sent to obtain a hemogram.", + "A lithium heparin sample was sent for biochemistry.", + "The hemogram was normal.", + "The reticulocyte count was 1.55%.", + "The reference range for reticulocytes is 0.9–2.6%.", + "Oncohematologic diseases were excluded by differential diagnosis.", + "The only finding on general biochemistry was cholesterol 248 mg/dL.", + "The reference range for cholesterol is <200 mg/dL.", + "The potassium level in plasma was 3.98 mmol/L.", + "The reference range for potassium in plasma is 3.4–4.5 mmol/L.", + "The creatinine level was 0.86 mg/dL.", + "The reference range for creatinine is 0.51–0.95 mg/dL.", + "The haptoglobin level was 39 mg/dL.", + "The reference range for haptoglobin is 30–200 mg/dL.", + "The hemolysis index was <6 mg/dL.", + "Laboratory analysis excluded hyperkalemia.", + "A possible case of familial pseudohyperkalemia was considered.", + "Three lithium heparin tubes were collected at the hospital.", + "Two aliquots were incubated at 4 °C for 2 and 4 h.", + "Two aliquots were incubated at 25 °C for 2 and 4 h.", + "Two aliquots were incubated at 37 °C for 2 and 4 h.", + "Centrifugation was performed after the incubation period was completed." + ], + "summary": "We present the case of a primary care female patient who persistently exhibited elevated levels of potassium (5.3-5.9 mmol/L) in successive control laboratory tests, without an apparent clinical cause. The patient was ultimately referred to the Unit of Nephrology, where a potassium-low diet was indicated. Diet did not have any effect on potassium levels. After a thorough study, the cause of hyperkalemia could not be determined.", + "summary_subclaims": [ + "The patient was a primary care female.", + "The patient had persistently elevated potassium levels.", + "Potassium levels ranged from 5.3 to 5.9 mmol/L in successive control tests.", + "There was no apparent clinical cause for the elevated potassium.", + "The patient was referred to the Unit of Nephrology.", + "A potassium-low diet was indicated.", + "The potassium-low diet did not affect potassium levels.", + "After a thorough study, the cause of hyperkalemia could not be determined." + ] + }, + { + "id": "multiclinsum_test_1697_en.txt", + "fulltext": "A 52-year-old male patient came to our clinic for a consultation regarding rashes on his fingers, arms and legs. It was learned from the patient’s story that he had been screened for the novel coronavirus (2019-nCoV) because his wife had tested positive two days previously. A reverse transcription polymerase chain reaction (RT-PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was found to be positive. The samples were obtained using a nasopharyngeal swab.\nHe had complaints of mild weakness and myalgia and he had been using tablets of diltiazem (120 mg/day), doxazosin (4 mg/day), atorvastatin (10 mg/day) and acetylsalicylic acid (100 mg/day) for five years due to essential hypertension and coronary artery disease. The patient did not complain of coughing or dyspnea, and no lung involvement was detected on computed tomography (CT). In laboratory tests, acute-phase reactants were found to be within the normal range: procalcitonin 0.005 ng/ml, sedimentation 12 mm/h and C-reactive protein (CRP) 8 mg/l. The patient was accepted as a COVID-19 case and treatments with hydroxychloroquine (600 mg BID for one day and then 400 mg BID for the following five days) and azithromycin (500 mg daily for five days) were started. Two days after the onset of constitutional symptoms, vesicular skin lesions started to develop on the finger’s side as can be seen in .\nInformed consent was obtained from the patient for publication of clinical pictures, and permission to report on this case was granted by the local ethics committee.\nThe patient’s first dermatological signs consisted of vesicles on the sides of his fingers and millimetric erythematous papulovesicular eruptions, which were concentrated on the extensor aspect of the lower legs and flexor aspect of the arms . Initially, the patient was evaluated as having irritant contact dermatitis, and administration of mometasone furoate ointment and cetirizine tablet (20 mg/day) was started. After three days, it was noticed that the patient’s existing lesions began to acquire a petechial-purpuric appearance and cherry angioma-like lesions appeared on his upper arms, extending from the inner side to the armpit, and on the upper lateral aspects of the trunk .\nIn laboratory tests, antinuclear antibody levels, antithrombin-3 levels, complete blood count, liver function tests and coagulation parameters were found to be within the normal range and conditions that cause vasculitis were ruled out. No histopathological examination of the skin lesions was performed because the patient did not agree to undergo a biopsy.\nThe patient developed severe weakness and severe muscle pain in his legs, which could be interpreted as restless leg syndrome. The skin manifestations gradually regressed leaving a reticular purpuric appearance. Some of the cherry angioma-like lesions disappeared after a brown crust had formed, while others persisted.", + "fulltext_subclaims": [ + "A 52-year-old male patient came to our clinic for a consultation regarding rashes on his fingers, arms and legs.", + "He had been screened for the novel coronavirus (2019-nCoV) because his wife had tested positive two days previously.", + "A reverse transcription polymerase chain reaction (RT-PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was found to be positive.", + "The samples were obtained using a nasopharyngeal swab.", + "He had complaints of mild weakness and myalgia.", + "He had been using tablets of diltiazem (120 mg/day), doxazosin (4 mg/day), atorvastatin (10 mg/day) and acetylsalicylic acid (100 mg/day) for five years due to essential hypertension and coronary artery disease.", + "The patient did not complain of coughing or dyspnea.", + "No lung involvement was detected on computed tomography (CT).", + "In laboratory tests, acute-phase reactants were found to be within the normal range: procalcitonin 0.005 ng/ml, sedimentation 12 mm/h and C-reactive protein (CRP) 8 mg/l.", + "The patient was accepted as a COVID-19 case.", + "Treatments with hydroxychloroquine (600 mg BID for one day and then 400 mg BID for the following five days) and azithromycin (500 mg daily for five days) were started.", + "Two days after the onset of constitutional symptoms, vesicular skin lesions started to develop on the finger’s side.", + "Informed consent was obtained from the patient for publication of clinical pictures.", + "Permission to report on this case was granted by the local ethics committee.", + "The patient’s first dermatological signs consisted of vesicles on the sides of his fingers and millimetric erythematous papulovesicular eruptions.", + "The eruptions were concentrated on the extensor aspect of the lower legs and flexor aspect of the arms.", + "Initially, the patient was evaluated as having irritant contact dermatitis.", + "Administration of mometasone furoate ointment and cetirizine tablet (20 mg/day) was started.", + "After three days, it was noticed that the patient’s existing lesions began to acquire a petechial-purpuric appearance.", + "Cherry angioma-like lesions appeared on his upper arms, extending from the inner side to the armpit, and on the upper lateral aspects of the trunk.", + "In laboratory tests, antinuclear antibody levels, antithrombin-3 levels, complete blood count, liver function tests and coagulation parameters were found to be within the normal range.", + "Conditions that cause vasculitis were ruled out.", + "No histopathological examination of the skin lesions was performed because the patient did not agree to undergo a biopsy.", + "The patient developed severe weakness and severe muscle pain in his legs.", + "The skin manifestations gradually regressed leaving a reticular purpuric appearance.", + "Some of the cherry angioma-like lesions disappeared after a brown crust had formed, while others persisted." + ], + "summary": "Here, we report a case of eruptive cherry angiomas, which was thought to have developed due to COVID-19, with a papulovesicular rash on distal extremities that progressed over time to reticular purpura.", + "summary_subclaims": [ + "The patient had eruptive cherry angiomas.", + "The condition was thought to have developed due to COVID-19.", + "The patient had a papulovesicular rash on distal extremities.", + "The rash progressed over time to reticular purpura." + ] + } +] \ No newline at end of file